Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 M E E T I N G A B S T R AC T S 30th International Symposium on Intensive Care and Emergency Medicine Brussels, Belgium, 9-12 March 2010 Published: 1 March 2010 P1 Comparison of carbamylated versus recombinant erythropoietin during spinal cord ischemia/reperfusion injury F Simon, A Scheuerle, A Soell, M Groeger, O McCook, P Radermacher, M Georgief, E Calzia, H Schelzig Ulm University, Ulm, Germany Critical Care 2010, 14(Suppl 1):P1 (doi: 10.1186/cc8233) Introduction We previously showed that erythropoietin (EPO) attenuates the morphological signs of spinal cord ischemia/reperfusion (I/R) injury in swine [1] without, however, improving neurological function. The clinical use of EPO has been cautioned most recently due to serious safety concerns arising from an increased mortality in acute stroke patients treated with EPO and simultaneously receiving systemic thrombolysis [2]. Carbamylated EPO (cEPO) is an EPO derivative without erythropoietic activity and devoid of the EPO side efects, but with apparently well maintained cytoprotective qualities [3]. We therefore tested the hypothesis whether cEPO may be equally eicient as EPO in reducing morphological as well as functional aortic occlusion-induced spinal cord I/R injury. Methods In a randomized and blinded trial pigs received either vehicle (control, n = 9), EPO or cEPO, respectively (n = 9 each; 5,000 IU/kg over 30 minutes before and during the irst 4 hours of reperfusion). Animals underwent 30 minutes of thoracic aortic balloon occlusion with catheters placed immediately downstream of the A. subclavia and upstream of the aortic trifurcation. Spinal cord function was assessed by motor evoked potentials (MEP as percentage of the amplitude before aortic occlusion) and lower limb relexes (assessed as the subjective strength of response) for a period of 10 hours after reperfusion. Tissue damage was evaluated using Nissl staining. Results Both EPO-treated and cEPO-treated animals presented with attenuated spinal cord injury in the Nissl staining (median (quartile) percentage of damaged neurons in the thoracic segments: control 27 (25,44), cEPO 8 (4,10), and EPO 5 (5,7), P <0.001 vs control group; in the lumbar segments: control 26 (19,32), cEPO 7 (5,13), EPO 8 (5,10), P <0.001 vs control group). However, while only cEPO treatment was associated with recovery of the MEP amplitude to pre-occlusion values when compared with the control group (P <0.05), lower limb relex response was comparably restored stronger in both treatment groups (P <0.05 vs control). Conclusions In a clinically relevant porcine model mimicking aortic crossclamping during vascular surgery repair of thoracic aortic aneurysm, cEPO protected spinal cord function and integrity as efective as EPO when applied at equipotent doses. Acknowledgements Supported by the Deutsche Forschungsgemeinschaft (SCHE 899/2-2). References 1. 2. 3. P2 Sodium 4-phenylbutylate protects against myocardial ischemia-reperfusion injury by reducing unfolded protein response-mediated apoptosis in mice M Okajima1, M Takamura2, S Usui2, T Taniguchi1, S Kaneko2 1 Kanazawa University Hospital, Kanazawa, Japan; 2Kanazawa University Graduate School of Medical Science, Kanazawa, Japan Critical Care 2010, 14(Suppl 1):P2 (doi: 10.1186/cc8234) Introduction Unfolded protein response (UPR)-mediated apoptosis plays a pivotal role in ischemia-reperfusion injury. Sodium 4-phenylbutyrate (PBA) has been reported to act as a chemical chaperone inhibiting UPR-mediated apoptosis triggered by ischemia in various organs other than the heart. Therefore we investigated whether PBA reduces UPR-mediated apoptosis and protects against myocardial ischemia-reperfusion injury in mice. Methods C57BL/6 mice were subjected to 30 minutes LAD ischemia followed by reperfusion. PBA (100 mg/kg) or PBS (control) was administrated intraperitoneally just before ischemia. Apoptosis, infarct size and tissue protein levels of Grp78 and caspase-12 (UPR-mediated apoptosisassociated protein) were evaluated by TUNEL, TTC stain and western blot analyses, respectively, at 48 hours after ischemia (n = 5 for each group). Echocardiography was performed at 3 weeks after ischemia and the survival ratio was observed (n = 9 for each group). Results Compared with PBS, PBA reduced apoptotic cells (30.8 ± 0.2% vs 20.5 ± 0.5%, P <0.05) and infarct size (32.0 ± 3.8% vs 13.0 ± 2.1%, P <0.01) after ischemia-reperfusion. Grp78 and caspase-12 were increased in mice with PBS, but PBA attenuated the increase in Grp78 (P <0.05) and caspase-12 (P <0.05). PBA inhibited the deterioration of cardiac parameters including LVEDD (3.35 ± 0.08 mm vs 2.74 ± 0.11 mm, P <0.01), LVESD (2.30 ± 0.08 mm vs 1.54 ± 0.12 mm, P <0.01), and %FS (31.3 ± 2.2% vs 39.4 ± 2.2%, P <0.05). All mice with PBA survived, but 33% animals with PBS died. Conclusions PBA maintained cardiac function and improved survival ratio after myocardial ischemia-reperfusion by reducing UPR-mediated apoptosis in mice. References 1. 2. Qi X, et al.: Mol Pharmacol 2004, 66:899-908. Vilatoba M, et al.: Surgery 2005, 138:342-351. Crit Care Med 2008, 36:2143-2150. Stroke 2009. [Epub ahead of print] J Int Med 2008, 264:405-432. © 2010 BioMed Central Ltd © 2010 BioMed Central Ltd Figure 1 (abstract P2). Phenylbutyrate reduced the unfolded protein response. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P3 Time-dependent efects of intravenous H2S during long-term, resuscitated porcine hemorrhagic shock H Bracht1, F Simon1, B Hauser1, M Groeger1, A Soell1, O McCook1, M Georgief1, P Radermacher1, C Szabo2, E Calzia1 1 Ulm University, Ulm, Germany; 2University of Texas Medical Branch, Galveston, TX, USA Critical Care 2010, 14(Suppl 1):P3 (doi: 10.1186/cc8235) Introduction In awake, spontaneously breathing mice, inhaling hydrogen sulide (H2S) induced a hibernation-like metabolic state characterised by reduced energy expenditure and hypothermia [1], which protected against otherwise lethal hypoxia [2] and hemorrhage [3]. In contrast, other authors reported that inhibition of endogenous H2S synthesis attenuated posthemorrhage organ dysfunction [4,5]. All these data originate, however, from unresuscitated models using a pre-treatment design. Therefore we investigated the time-dependent efect of intravenous H2S in a clinically relevant, long-term model of porcine hemorrhage and resuscitation. Methods After surgical instrumentation, pigs were subjected to 4 hours of hemorrhagic shock induced by removal of 40% of the calculated blood volume and thereafter by additional removal or retransfusion of blood boli as needed to maintain MAP = 30 mmHg. Animals randomly received vehicle (control, n = 14) or the intravenous H2S donor Na2S started 2 hours before hemorrhage (pre-treatment, n = 11), at the beginning of blood removal (early post-treatment, n = 10) or at the beginning of resuscitation (late post-treatment, n = 10). In all groups the Na2S infusion was continued over the irst 10 hours of reperfusion. Resuscitation comprised retransfusion of shed blood, colloid volume expansion, and noradrenaline titrated to keep MAP at pre-shock levels. Systemic, renal and liver perfusion, O2 exchange, and organ function were assessed before and at the end of hemorrhage as well as at 10 and 22 hours of resuscitation. Results Survival (71% in the control vs 100, 91, and 90% in the pretreatment, early post-treatment and late post-treatment groups, respectively) was signiicantly improved in all treatment groups. The noradrenaline infusion rate required to maintain hemodynamic targets was signiicantly reduced in the early post-treatment group only, which coincided with a progressive drop in core temperature and attenuated kidney dysfunction (blood creatinine levels, creatinine clearance) in these animals. Conclusions Na2S application improved survival regardless of the drug timing. The less beneicial efect of pre-treatment on organ function may be due to the higher total amount of drug infused, possibly suggesting some toxicity at these doses. Acknowledgements Supported by the German Ministry of Defence, and Ikaria Inc., Seattle, WA, USA. References 1. 2. 3. 4. 5. Science 2005, 308:518. Shock 2007, 27:370-372. J Trauma 2008, 65:183-187. Br J Pharmacol 2004, 143:881-889. Inlamm Res 2008, 57:512-518. P4 An ovine intensive care model of septic shock M Chapman1, M Maiden1, J Fraser1, C Nash1, F Crichton1, P Sideris2, T Kuchel2 1 Royal Adelaide Hospital, Adelaide, Australia; 2IMVS, Adelaide, Australia Critical Care 2010, 14(Suppl 1):P4 (doi: 10.1186/cc8236) Introduction Translation of previous animal studies into human ICU clinical trials has frequently produced negative results. Most of these animal studies have had high baseline mortality and have not employed standardised management of sepsis as usually provided in an ICU. The aim of this study was to develop a large animal model of septic shock receiving standardised intensive care management, thus replicating the management of septic shock in humans. Methods Eleven Marino ewes (weight 60 to 70 kg, hemiazygous vein ligated) were anaesthetised and had radiological guided catheters inserted into the iliac, renal, and hepatic veins, coronary sinus, and the pulmonary and carotid arteries. Tracheostomy tubes were inserted and S2 the animals mechanically ventilated while supported in a sling. Six sheep were administered intravenous E. coli (ATCC 25922) 1.0 x 108 orgs/kg over 1 hour (septic sheep), ive received placebo (nonseptic sheep). For 24 hours, animals were monitored and received sedation (midazolam + ketamine), ventilation, luids and inotropes according to a protocol. Primary end-point was noradrenaline (NA) dose to maintain mean arterial pressure (MAP) of 75 mmHg. Secondary end-points included haemodynamic variables, respiratory, hepatic, and renal function, haematology, acid–base status and global, hind-limb, renal, hepatic and coronary oxygen extraction ratio (OER). Results Sheep were successfully instrumented, monitored and supported for 24 hours. Septic sheep required NA (mean dose 0.28 μg/kg/min vs 0.00, P <0.001), developed a higher cardiac index (6.6 l/m2 vs 4.3, P <0.05) and lower SVRI (769 dynes/m2 vs 1,804, P <0.05). At 24 hours, septic sheep had renal impairment (creatinine 286 mmol/l vs 76, P <0.05; urea 12 mmol/l vs 7, P <0.05), metabolic acidosis (pH 7.21 vs 7.39, P <0.05; lactate 10.9 mmol/l vs 1.2, P <0.01; pCO2 32 vs 31, P = 0.63), coagulopathy (INR 5.9 vs 1.9, P <0.05; ibrinogen 0.9 g/l vs 2.7, P <0.05) but preserved respiratory and hepatic function. Global OER was lower in septic sheep (0.16 vs 0.29, P <0.05) as was coronary OER (0.36 vs 0.68, P <0.05). OER did not change with sepsis in the kidney (0.09 vs 0.11, P = 0.52), liver (0.24 vs 0.31, P = 0.48) and hind-limb (0.31 vs 0.42, P = 0.23). Conclusions We have developed a large animal model of septic shock that receives intensive care support and standardised management. This model replicates much of the pathophysiology and management that occurs in human septic shock. It allows a large range of physiological parameters to be assessed when investigating new therapies for sepsis. P5 Efects of temperature and H2S inhalation on glucose metabolism in murine resuscitated septic shock K Baumgart1, F Wagner1, V Hysa1, J Vogt1, U Wachter1, S Weber1, M Georgief1, P Radermacher1, C Szabo2, E Calzia1 1 Ulm University, Ulm, Germany; 2University of Texas Medical Branch, Galveston, TX, USA Critical Care 2010, 14(Suppl 1):P5 (doi: 10.1186/cc8237) Introduction In awake, spontaneously breathing mice, inhaling hydrogen sulide (H2S) induced a hibernation-like metabolic state characterised by reduced energy expenditure and hypothermia [1], which protected against otherwise lethal hypoxia [2] and hemorrhage [3] as a result of impaired cellular energy metabolism [4]. Therefore, we investigated the metabolic efects of inhaled H2S in our model of resuscitated murine septic shock. Methods Sixteen hours after induction of sepsis by cecal ligation and puncture (CLP) or sham operation, anesthetized and mechanically ventilated mice received 100 ppm H2S or vehicle over 5 hours at body temperatures of 38 and 27°C, respectively. During the observation period, hyperdynamic hemodynamics were maintained by colloid resuscitation and noradrenaline infusion [5]. Endogenous glucose production was calculated from blood 13 C6-glucose isotope enrichment derived from the rate of appearance of stable, non-radioactive labeled 1,2,3,4,5,6-13C6 glucose during continuous isotope infusion [6]. Whole-body glucose oxidation rate was derived from the total CO2-production rate, the mixed expiratory 13CO2/12CO2 isotope ratio and the 13 C6-glucose infusion rate after the steady state was achieved. Results While endogenous glucose production was not afected by hypothermia, it was signiicantly higher in the septic animals when compared with the corresponding sham operated groups, most likely due to the ongoing noradrenaline infusion. In contrast, despite the catecholamine infusion and higher glucose release, whole body glucose oxidation was signiicantly reduced in normothermic septic animals. During hypothermia, H2S shifted substrate towards preferential glucose utilisation, but this efect disappeared in the septic mice. Conclusions H2S inhalation alone does not inluence glucose metabolism once temperature is maintained at normothermic levels in anesthetised and mechanically ventilated mice. The H2S-related shift of energy metabolism towards preferential carbohydrate oxidation present during hypothermia is blunted during sepsis, possibly as a result of the ongoing catecholamine treatment. Acknowledgements Supported by the Deutsche Sepsis Gesellschaft, the DFG KFO 200, and Ikaria Inc., Seattle, WA, USA. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 References 1. 2. 3. 4. 5. 6. Science 2005, 308:518. Shock 2007, 27:370-372. J Trauma 2008, 65:183-187. J Am Soc Nephrol 2009, 20:1901-1905. Intensive Care Med 2009, 35:344-349. Crit Care Med 2010, 38:in press. P6 Mitochondrial respiration and cytochrome c inhibition by sulide in peritoneal macrophages in vitro: efects of temperature and pH M Groeger1, F Wagner1, K Baumgart1, M Huber-Lang1, M Knoeferl1, M Georgief1, P Radermacher1, C Szabo2, E Calzia1 1 Ulm University, Ulm, Germany; 2University of Texas Medical Branch, Galveston, TX, USA Critical Care 2010, 14(Suppl 1):P6 (doi: 10.1186/cc8238) Introduction Hydrogen sulide (H2S) is a potent inhibitor of cytochrome c oxidase (COX) and, thus, of mitochondrial respiration [1]. Since H2S was reported to induce a suspended animation-like status characterized by reduced energy expenditure and hypothermia [2], we sought to determine the efect of hypothermia on mitochondrial respiratory capacity and H2Srelated COX inhibition. We further studied the inluence of variations in pH on both variables. Methods All measurements were conducted in digitonin-permeabilised cultured peritoneal macrophages using high-resolution respirometry [3] (Oxygraph-2k, Oroboros, Austria). Maximum mitochondrial respiration (1 to 2 Mio cells/ml respiration medium) was achieved in the uncoupled state by adding pyruvate, malate, glutamate and succinate as respiratory substrates. Then, in one of the two chambers of the oxygraph, mitochondrial respiration was inhibited stepwise by incremental concentrations of the H2S donor Na2S (1 to 64 μM). In the parallel chamber, the identical inhibitor titration sequence was preceded by the inhibition of the respiratory chain by rotenone and antimycin A followed by the selective stimulation of the COX after addition of ascorbate and TMPD. COX excess capacity (% of OXPHOS) was calculated based on the ratio of inhibition of mitochondrial respiration with full operating respiratory chain versus the COX-stimulated condition. This experimental sequence was repeated at 37°C and 25°C with a medium pH of 7.1 and then at 37°C with a pH of 6.8 and 7.7. Results COX excess capacity (median (quartiles)) was signiicantly higher at 25°C than at 37°C (134 (113; 140) vs 61 (47; 79)), most likely due to the almost halved mitochondrial respiratory capacity at hypothermia (50 (37; 63) vs 95 (81; 103) pmolO2/s x Mio cells). Changing the medium pH from 6.8 to 7.7 signiicantly increased the COX excess capacity (91 (79; 103) vs 71 (64; 82) pmolO2/s x Mio cells), which again was related to the signiicantly lower mitochondrial respiratory capacity with more acidic conditions (80 (70; 89) vs 94 (85; 98)). Conclusions Our results suggest that COX excess capacity is temperature as well as pH dependent in peritoneal macrophages. This efect may protect cells from H2S toxicity at low temperatures and high pH values. Acknowledgements Supported by the Deutsche Forschungsgemeinschaft (KFO 200). References 1. 2. 3. Science 2005, 308:518. Toxicol Sci 2002, 65:18-25. Biochim Biophys Acta 2006, S14:201-202. P7 Alterations of caspase 9 mRNA gene expression in survivors and nonsurvivors of severe sepsis M White1, D Doherty2, D Kelleher2, R McManus2, T Ryan1 1 St James Hospital, Dublin, Ireland; 2Trinity College, Dublin, Ireland Critical Care 2010, 14(Suppl 1):P7 (doi: 10.1186/cc8239) Introduction Sepsis-induced lymphocyte apoptosis plays a fundamental role in the pathophysiology of sepsis. Recent animal models of sepsis have identiied anomalies in the extrinsic apoptotic pathway, a key pathological occurrence in sepsis [1]. Speciically apoptosis markers such as caspases S3 1, 3, 8, 9 and FADD have been shown to be signiicant in animal models of infection [2].We investigated mRNA transcription of these markers in a human model of severe sepsis. We hypothesized that ICU mortality from severe sepsis is associated with distinctive gene expression of extrinsic apoptosis markers. Methods A prospective observational study of patients with severe sepsis was performed. Mononuclear cells were isolated from 48 patients with severe sepsis. Total RNA was extracted from samples for day 1 of admission and again on day 7. FADD, caspase 1, 3, 8, and 9 mRNA was quantiied with quantitative real-time polymerase chain reaction (qRT-PCR). Standard demographic and outcome data were recorded. Between-group comparisons were performed by Wilcoxon rank sum test. All values are stated as median and interquartile range. Results Sixteen of the 48 patients died in the ICU. Caspase 9 mRNA copy numbers were signiicantly increased on day 7 in the survivor group (5.4 x 106; 7.4 x 106 to 8.9 x 106) compared with death in the ICU group (1.9 x 106; 3.0 x 106 to 1.2 x 106) P = 0.001. FADD, caspase 1, 3 and 8 mRNA copy numbers were not signiicantly diferent between patients who died and those discharged from the ICU on either day 1 or day 7 of admission. Conclusions Caspase 9 may be an important regulator of apoptotic mechanisms in humans with late sepsis. Pro-apoptotic mechanisms may have a role in the resolution of severe sepsis. Acknowledgements This study is funded by the Association of Anaesthetists of Great Britain and Ireland and the Intensive Care Society Ireland. References 1. 2. Oberholzer C, et al.: Apoptosis in sepsis: a new target for therapeutic exploration. FASEB J 2001, 15:879-892. Hotchkiss R, et al.: Accelerated lymphocyte death in sepsis occurs by both the death receptor and mitochrondrial pathways. J Immunol 2005, 174:5110-5118. P8 The TLR4 antagonist CRX-526 reduces LPS-induced leukocyte activation and improves capillary perfusion of the rat intestine M Soltow1, K Zimmermann1, D Pavlovic1, J Zhou2, S Whynot2, O Hung2, M Murphy2, B Johnston2, C Lehmann2 1 Ernst Moritz Arndt University, Greifswald, Germany; 2Dalhousie University, Halifax, Canada Critical Care 2010, 14(Suppl 1):P8 (doi: 10.1186/cc8240) Introduction Toll-like receptor 4 (TLR4) represents an important mediator of endotoxin-related signal transduction. The aim of our study was to evaluate whether TLR4 inhibition after onset of experimental endotoxemia is able to improve the intestinal microcirculation, which is crucial in the pathogenesis of septic multiple organ failure. Methods We studied four groups of animals (Lewis rats, n = 10 per group): healthy controls (CON group), endotoxemic animals (15 mg/kg lipopolysaccharide, LPS group), endotoxemic animals treated with TLR4 antagonist (1 mg/kg CRX-526, LPS + CRX group), and CRX-526 treated controls (CRX group). Intravital microscopy of the intestinal microcirculation was performed following 2 hours of observation in all animals. Blood samples were taken for cytokine measurements at the end of the experiments. Results Following 2 hours of endotoxemia we observed a signiicant increase of leukocyte adhesion in the intestinal submocosal venules (for example, V1 venules: CON 20.4 ± 6.5 n/mm2, LPS 237.5 ± 36.2 n/ mm2, P <0.05). Capillary perfusion of the muscular and mucosal layers of the intestinal wall was signiicantly reduced (for example, longitudinal muscular layer: CON 112.5 ± 5.9 cm/cm2, LPS 71.3 ± 11.0 cm/cm2). TLR4 inhibition reduced leukocyte activation (V1 venules: 104.3 ± 7.8 n/mm2) and improved capillary perfusion (longitudinal muscular layer: 111.0 ± 12.3 cm/cm2) signiicantly. Cytokine release was not afected. Conclusions Administration of the TLR4 antagonist CRX-526 improved intestinal microcirculation in a post-treatment model of experimental endotoxemia. The TLR4 pathway may be a target in clinical Gram-negative sepsis. References 1. 2. 3. 4. Cristofaro et al.: Drugs 2006, 66:15. Fort et al.: J Immunol 2005, 74:6416. Moue et al.: Biochim Biophys Acta 2008, 1780:134. Zanotti et al.: Am J Physiol Lung Cell Mol Physiol 2009, 297:L52. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P9 Efects of lipopolysaccharide on isolated muscle mitochondrial respiration are dose and time dependent S Brandt1, S Djafarzadeh2, J Takala2, SM Jakob2 1 University of Bern, Switzerland; 2Department of Intensive Care Medicine, University of Bern, Switzerland Critical Care 2010, 14(Suppl 1):P9 (doi: 10.1186/cc8241) Introduction There is evidence that mitochondrial dysfunction plays a role in sepsis-related tissue damage. Several studies described the uptake and endocytosis of lipopolysaccharide (LPS) by various cells. LPS has been localized in diferent parts of the cytoplasm, including at close proximity to or within mitochondria [1]. Whether efects of LPS on mitochondrial respiration are time and/or dose dependent is unknown. Methods Quadriceps muscle biopsy was taken from seven anaesthetized pigs. Mitochondria were isolated using diferential centrifugation and immediately incubated with 0.1, 1, 10, 50 and 100 μg LPS per mg mitochondria protein on ice for 2 and 4 hours. Respiration rates were determined polarographically using glutamate and succinate as substrates to test the function of complex I and II. Respiration Control Ratio (State 3/ State 4) was derived for each substrate. Repeated-measures ANOVA was used to analyze time and dose efect of LPS on respiration rates. Results The results are shown in Figure 1. Conclusions In vitro, LPS has time-dependent and dose-dependent efects on muscle mitochondrial respiration. This has consequences for design and interpretation of experimental studies. References 1. Diaz-Laviada I, et al.: Histochem J 1991, 23:221-228. P10 Clinical severity and local inlammatory responses in animal models of sepsis S Saeed, D Gilroy, M Singer University College London, UK Critical Care 2010, 14(Suppl 1):P10 (doi: 10.1186/cc8242) Introduction Severe sepsis carries high morbidity and mortality. Preclinical research predominantly utilises animal models although their reproducibility may vary, thus impairing understanding of disease. We sought to determine the reproducibility of two murine models by assessing clinical severity and local immune cell response 24 hours after septic insult. Figure 1 (abstract P9). Mean ± SD. Boxes: μg/mg LPS. S4 Methods Intraperitoneal faecal slurry (FS) or zymosan was given to induce acute peritonitis in 11 and 12 male C57/Bl mice (8 to 12 weeks, 18 to 32 g). A control group received saline only (n = 5). In surviving animals at 24 hours, clinical severity was scored as severe, moderate or mild according to appearance and alertness. Peritoneal lavage was performed to obtain immune cells. Analysis by antibody labelling (F4/80, GR-1, CD3 and CD19) for luorescence-assisted cell sorting identiied numbers of macrophages, neutrophils, T and B cells. Logistic regression (odds ratio, OR) was used to determine the relationship of cell numbers with severity (reported if P <0.05). Results Clinical severity varied markedly despite similar dosing (see Table 1). At 24 hours, total intraperitoneal immune cells increased in both models and with clinical severity (OR 0.83). Neutrophils predominated after septic insult and also rose with severity (OR 0.75). Compared with control, macrophage populations did not change in either model while B and T lymphocytes fell. A cell population that expressed both F4/80 and GR-1 – that is, markers for macrophages and neutrophils, respectively – occurred only in the FS model. Table 1 (abstract P10). Number of animals according to clinical severity (with inclusive mortality) Faecal slurry Zymosan Severe Moderate Mild 6 (2) 4 (2) 0 5 5 3 Conclusions Individual variability occurs in both faecal and zymosan peritonitis models as shown by heterogeneous clinical responses and local immune cell numbers to the same dose in similar animals. The cellular immune response in both models is consistent with current understanding of infection-induced inlammation. Neutrophils, but not macrophages, rose in proportion to worsening clinical severity. The signiicance of F4/80+/GR-1+ cells in the FS model requires further evaluation. P11 Adenosine increases during human experimental endotoxemia, but does not inluence the immune response and subsequent organ injury B Ramakers, N Riksen, B Franke, P Pickkers, H Van der Hoeven Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands Critical Care 2010, 14(Suppl 1):P11 (doi: 10.1186/cc8243) Introduction Although the innate immune response protects the host from invading pathogens, an excessive response may also lead to Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 collateral damage to normal tissues. Adenosine has been proposed as an immunomodulator capable of inhibiting inlammation and preventing tissue injury. The C34T nonsense mutation in the AMP deaminase 1 (AMPD1) gene is thought to increase the endogenous adenosine concentration and has been associated with improved prognosis and survival in ischemic heart disease. Cafeine on the other hand, acting as a nonselective adenosine receptor antagonist, could diminish adenosine-mediated efects. The present study evaluated the endotoxemia-induced adenosine response, subclinical renal damage and endothelium dysfunction in healthy male subjects. Furthermore, we investigated whether the LPSinduced inlammatory response is attenuated by AMPD1 and enhanced by cafeine, as well as its efects on markers of endothelium activation (plasma ICAM, VCAM) and renal damage (urinary excretion of GSTA1-1 and GSTP1-1). Methods Thirty healthy male subjects received 2 ng/kg E. coli LPS. Three groups were evaluated in a double-blind randomized controlled setting; a LPS-placebo group (n = 10), LPS-placebo in AMPD1 subjects (n = 10), and a LPS-cafeine group (4 mg/kg, n = 10). Results During endotoxemia, the adenosine concentration increased from 10.0 ng/ml (9.0 to 15.3) at baseline to 15.5 ng/ml (13.0 to 22.3) 2 hours after LPS infusion (P = 0.003; Friedman). The response was similar between LPS groups. The increase in proinlammatory and anti-inlammatory cytokines (TNFα, IL-6, IL-10 and IL1RA) was similar in the three groups. Experimental endotoxemia resulted in endothelial dysfunction, measured by an increase in adhesion molecules and subclinical renal injury as measured by GSTA11 and GSTP1-1. Inlammation induced subclinical end-organ damage was not inluenced by either the AMPD1 SNP or treatment with cafeine. Conclusions Human experimental endotoxemia induces an increase in circulating cytokine levels and subclinical endothelial and renal damage. Acute systemic inlammation is also associated with an increase in endogenous adenosine concentrations. Modulation of the adenosine metabolism through the presence of the AMPD1 and administration of cafeine does not afect the innate immune response and its subsequent subclinical organ dysfunction. P12 Bacterial load plays a crucial role for survival in experimental peritonitis and modulates immunoparalysis of monocytes S Atmatzidis1, K Louis2, A Pistiki2, I Koutelidakis1, T Adamis2, E Giamarellos-Bourboulis2 1 Thessaloniki, Medical School, Thessaloniki, Greece; 2ATTIKON University Hospital, Athens, Greece Critical Care 2010, 14(Suppl 1):P12 (doi: 10.1186/cc8244) Introduction Peritonitis is the prototype of polymicrobial sepsis with kinetics of bacterial growth difering from those of other infections leading to sepsis. The efect of the extent of leaking of gut content in the response of the host was studied. Methods A total of 21 rabbits were studied divided into two groups; A: high-load peritonitis; and B: normal load peritonitis. After a midline abdominal incision, the ileocecal calve was ligated. Three holes were performed in the cecum wall of group A followed by masturbation to drain cecal content in the peritoneal cavity. Two holes without masturbation were performed in group B. After closure of the abdominal cavity, blood was sampled at 2, 4, 24 and 48 hours. Peripheral blood mononuclear cells (PBMCs) were isolated and stimulated in microplate wells with 10 ng/ml LPS. Concentrations of TNFα were estimated in supernatants by a bioassay in L929 ibrosarcoma cell line. In parallel, monocytes were separated from lymphocytes by plastic adherence. Apoptosis was estimated after staining with ANNEXIN-V and PI and low cytometric analysis. Tissue bacterial growth was estimated after death. Results Mortality after 14 days was 84.6% in group A and 62.5% in group B (log-rank: 3.83, P = 0.050). Mean respective rates of apoptosis of lymhocytes of groups A and B were 32.2 and 44.5% at 2 hours; 33.5 and 51.9% at 4 hours (P = 0.028); 35.6 and 39.1% at 24 hours; and 28.5 and 43.7% at 48 hours (P = 0.029). Mean respective rates of apoptosis of monocytes of groups A and B were 48.2 and 64.1% at 2 hours (P = 0.036); 57.9 and 66.3% at 4 hours; 47.3 and 69.9% at 24 hours (P = 0.041); and 60.5 and 73.5% at 48 hours. Respective TNFα released ex vivo from PBMCs isolated at 24 hours from groups A and B after LPS stimulation was 2,579.1 and 31.3 pg/ml (P = 0.048). Mean respective log10 of enterobacteriaceae of S5 groups A and B were 6.52 and 1.39 cfu/ml in liver (P = 0.012); 7.79 and 1.43 cfu/ml in spleen (P = 0.012); and 7.98 and 1.79 cfu/ml in the right kidney (P = 0.012). Conclusions Experimental peritonitis with enormous bacterial leaking from the gut is accompanied by reduced survival, increased tissue bacterial growth and reduced apoptosis of lymphocytes and monocytes. Peritonitis with low bacterial leaking is characterized by immunoparalysis of PBMCs. These results may project in the eicacy of immunotherapy in abdominal sepsis. P13 Decreased whole blood TNFα production capacity after acute alcohol exposure and LPS stimulation ex vivo A Gavala1, K Venetsanou2, C Kittas3, E Manolis4, A Yiambides2, P Myrianthefs2, G Baltopoulos2 1 KAT, Kiisia, Greece; 2ICU, KAT Hospital, School of Nursing, Athens University, Athens, Greece; 3Medical School, Athens University, Athens, Greece; 4School of Nursing, Athens University, Athens, Greece Critical Care 2010, 14(Suppl 1):P13 (doi: 10.1186/cc8245) Introduction Acute alcohol exposure is related to increased susceptibility to infections [1]. The purpose of the study was to investigate the efect of acute exposure to diferent alcohol concentrations in whole blood TNFα production capacity after LPS stimulation ex vivo in healthy men. Methods Whole blood was taken from healthy volunteers and was placed in tubes containing EDTA and immediately transferred to the lab. Heparinized blood samples diluted 1:10 in RPMI 1640 culture medium (100 μl whole blood added in 900 μl RPMI 1640). Samples were preincubated with 0‚ 5‚ 12.5‚ 25‚ 50‚ 100 and 200 mM alcohol (EtOH) for 10 minutes at room temperature. After incubation, 500 pg LPS was added in each sample for 4 hours at 37°C. At the end of the process, samples were centrifuged (1,800 rpm, 5 minutes, r.t.). Culture supernatants were collected and stored at –70°C until measurements. TNFα levels were determined in culture supernatant with ELISA [2]. Results We studied 17 healthy males volunteers aged 36.9 ± 1.6 (X ± SEM). TNFα levels are shown in Figure 1. There was no TNFα production detected in samples without alcohol in the absence of LPS stimulation (control). TNFα production was signiicantly decreased at a dose of alcohol of 50 mM after LPS stimulation (P <0.05) but more apparently at doses of 100 and 200 mM alcohol (P <0.001) compared with LPS-induced samples. Conclusions Alcohol is related to inhibition of TNFα production of whole blood stimulated with LPS ex vivo [3]. This efect occurred shortly after alcohol exposure. Our observation indicates a suppression of proinlammatory response during acute alcoholic intoxication which may be related to increased susceptibility to infections. References 1. 2. 3. Brown LA‚ et al.: Alcohol Clin Exp Res 2006, 30:1624-1631. Myrianthefs P, et al.: Cytokine 2003, 24:286-292. Nair M‚ et al.: Alcohol Clin Exp Res 1994, 18:602-607. Figure 1 (abstract P13). Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P14 Leukocyte immunophenotyping: methodological aspects J Jämsä, V Huotari, ER Savolainen, H Syrjälä, T Ala-Kokko Oulu University Hospital, University of Oulu, Finland Critical Care 2010, 14(Suppl 1):P14 (doi: 10.1186/cc8246) Introduction Flow cytometric analysis of leukocyte surface receptors has been performed and shown beneicial, for example to characterize infectious and septic patients [1,2]. For many surface antigens the results may vary depending on the sampling temperature, the anticoagulant used and the storage of the sample before analysis [3]. In order to obtain reliable data on leukocyte immunophenotyping for patient diagnostic purposes, we wanted to carry out a thorough evaluation on these methodological issues with a wide range of leukocyte surface antigens. Methods Four blood samples, two using acid citrate dextrose (ACD) and two using heparin as an anticoagulant, were taken from ive ICU patients with severe sepsis and from ive healthy volunteers. The patients and the healthy volunteers were combined into one study population (n = 10). The samples were taken, processed and stored either at +4°C or at room temperature. The surface antigen staining and low cytometry were performed immediately after sample collection or after 6 or 24 hours at the above-mentioned temperatures. Antibodies of interest were for monocytes and neutrophils CD11b and CD64, for monocytes CD14, CD40, CD80, human leukocyte antigen (HLA)-DR, and for lymphocytes (CD4+ and CD8+ T cells, B cells, and NK cells) CD69. The low cytometry analysis was done in three diferent time points, after 1, 6 or 24 hours of sampling. Interassay standardization and luorescence quantiications were performed using microspheres. Results The luorescence intensities were higher at room temperature compared with +4°C and they increased after storage (Figure 1). The efect was observed especially for CD11b-antigen in monocytes and neutrophils and for HLA-DR in monocytes. Conclusions According to our results, low cytometry leukocyte analysis using CD antigens should be performed using +4°C temperature throughout the measurement including sample collection, preparation and storage, and the analysis should be performed within 6 hours. References 1. 2. 3. S6 P15 Phenotypical analysis of peripheral human T lymphocytes in early sepsis M Nalos, B Santner-Nanan, L Weisbrodt, AS Mclean, R Nanan Sydney Medical School – Nepean, The University of Sydney, Penrith, Australia Critical Care 2010, 14(Suppl 1):P15 (doi: 10.1186/cc8247) Introduction T lymphocytes are crucial immune cells. We analysed T-cell subsets phenotypes and tested, on a single cell level, their ability to produce key cytokines in early human sepsis. Methods Whole blood was collected from septic patients on ICU admission. Peripheral blood mononuclear cells (PBMC) were isolated and T-cell subsets analysed. To study cytokine production, PMBC were cultured in the presence of PMA/ionomycin (50/750 ng/ml) in supplemented RPMI 1640 for 5 hours. Intracellular cytokines IL-4, IL-10, IL-17, IFNγ were stained in CD3+/CD4+, CD3+/CD8+ cells using low cytometry for both. The number of cytokine producing cells was compared with age/sex-matched healthy human volunteers. Data are expressed as mean ± SEM. Results There were 12 patients (66 years old, six males, APACHE II-24, eight survivors) and nine volunteers. We found a relative increase in the frequency of Treg cells while the proportion of CD4+ cells remained unchanged in septic patients. The PMA/ionomycin lead to maximal T-cell stimulation, testing the ability of individual cell subsets to produce cytokines. Septic patients displayed reduction of IFNγ (10.5 ± 0.8% vs 14.7 ± 1.9%, P <0.01) and a tendency to higher number of IL-10 (1.7 ± 0.3% vs 0.5 ± 0.1%, P = 0.10) producing CD4+ cells, while the proportion of IFNγ-positive CD8+ cells increased (42.8 ± 5.8% vs 28.1 ± 4.9%, P = 0.03). However, the overall CD8+ T-cell population was reduced (14.29 ± 1.6% vs 25 ± 1.2%) following ex vivo activation in patients. The number of IL-4 and IL-17 staining cells was unchanged (Figure 1). Conclusions Our results conirm a relative increase of Treg [1] and a skew towards Th2 lineage in the CD4+ cells. The highly activated CD8+ cells appear to be more susceptible to activation-induced cell death. References 1. Venet F et al.: Intensive Care Med 2009, 35:678-686. Payden et al.: Minerva Anest 2009, 75:484-493. Nuutila et al.: Hum Immunol 2009, 70:237-243. Li et al.: Eur J Haematol 2000, 65:57-65. Figure 1 (abstract P14). CD11b luorescence intensity for neutrophils (n = 10). Figure 1 (abstract P15). Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Figure 1 (abstract P16). CD64 kinetics (units). S7 blood cells, platelets and temperature were also monitored. Values are expressed as median (25th to 75th) percentile. Results CD64 index (Figure 1) slightly rose from the day 0, median value 0.86 units (1.06 to 1.38 units) to day 5 after the surgery, 1.01 (1.32 to 1.68 units). However, this increase was moderate, and the median values did not exceed the usual threshold of 1.5 units. Conversely, CRP showed a large increase from normal values on day 0 to 8, 67 mg/dl (6.64 to 13.56 mg/dl) on day 5. No signiicant correlation (P >0.05) was found between CD64 and the others parameters of inlammation (CRP, leukocyte count, PMNs, platelets and temperature). Conclusions Our results show that the neutrophil CD64 expression after cardiac surgery with ECC is only moderately increased. The role of this new biomarker in the early diagnosis of infection (after major surgery) should be assessed in prospective studies. References 1. P16 CD64, a marker of leucocyte activation kinetics after uncomplicated cardiac surgery S Djebara, P Cauchie, A Alewaeters, A Daper, E Fosse, K Zouaoui Boujelta, P Biston CHU Charleroi, Charleroi, Belgium Critical Care 2010, 14(Suppl 1):P16 (doi: 10.1186/cc8248) Introduction The aim of this study was to assess the CD64 kinetics after normal cardiac surgery, an essential step to deine the potential use of CD64 as an early and speciic infectious marker in this postoperative setting. CD64 is a high-ainity receptor for the Fc portion of IgG. It is weakly expressed on the polynuclear neutrophils (PMNs) at rest [1,2] but increases speciically after bacterial stimulation. Thus, CD64 analysis is proposed as an early infectious marker. Methods Prospective study realised in the medico-surgical ICU of CHU Charleroi (Belgium). Twenty-two patients (mean age 64 ± 13 years) scheduled for cardiac surgery were included in the analysis. The CD64 expression on neutrophils was quantiied by the haematologic cell dyn sapphire method (Abott, USA). C-reactive protein, leukocyte count, white Figure 1 (abstract P17). Efect of IFNγ on the release of TNFα. 2. Loan-Facsinay A, de Kimpe SJ, Hellwig SMM, et al.: FcγRI(CD64) contributes substantially to severities of arthritis, hypersensitivity responses, and protection from bacterial infection. Immunity 2002, 16:391-402. Harpaz Y, Chothia C: Many of the immunoglobulin superfamily domains in cell adhesion molecules and surface receptors belong to a new structural set which is close to that containing variable domains. J Mol Biol 1994, 238:528-539. P17 Interferon-gamma reverses sepsis-induced immunoparalysis of monocytes in vitro M Mouktaroudi, A Savva, A Pistiki, M Raftogiannis, A Antonopoulou, E Giamarellos-Bourboulis ATTIKON University Hospital, Athens, Greece Critical Care 2010, 14(Suppl 1):P17 (doi: 10.1186/cc8249) Introduction It is currently being understood that most of the agents modulating host response in sepsis have failed because they act to refrain an over-exaggerated immune response whereas immunoparalysis takes place on the time of their administration. The efect of IFNγ on immunoparalysis of monocytes in sepsis was assessed. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Methods Blood was isolated within the irst 24 hours from the advent of signs of sepsis from 10 healthy donors and from 33 patients; 14 with sepsis and 19 with severe sepsis/shock. Peripheral blood mononuclear cells (PBMCs) were isolated and stimulated with 10 ng/ml LPS; 5 μg/ml Pam3Cys; and heat-killed isolates of Candida albicans, multidrug-resistant Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA). Stimulations were done in the absence and presence of 10 ng/ ml IFNγ. Concentrations of cytokines were estimated in supernatants by an enzyme immunoassay. Results Efects of IFNγ on the release of TNFα are shown in Figure 1. Open bars represent stimulation in the absence of IFNγ and solid bars stimulation in the presence of IFNγ. Asterisks signify diferences compared with the absence of IFNγ. IL-6 and IL-1β had similar kinetics to TNFα. Conclusions IFNγ reverses in vitro sepsis-induced immunoparalysis of monocytes. The type of afected cytokine depends on the agonist and probably relects the mechanism of action of IFNγ. P18 Early hydrocortisone treatment counteracts circulatory derangement but not cytokine response in porcine endotoxemia ES Söderberg1, ML Lipcsey1, JS Sjölin2, AL Larsson3, ME Eriksson1 1 Section of Anaesthesiology and Intensive Care, Uppsala, Sweden; 2Section of Infectious Diseases, Uppsala, Sweden; 3Section of Clinical Chemistry, Uppsala, Sweden Critical Care 2010, 14(Suppl 1):P18 (doi: 10.1186/cc8250) Introduction We evaluated whether treatment with hydrocortisone administered just after establishment of endotoxin-mediated circulatory dysfunction would have anti-inlammatory and shock reversing efects. Establishment of endotoxin-mediated circulatory dysfunction was deined as the moment when the mean pulmonary arterial pressure (MPAP) reached the double baseline value. Methods All pigs were anesthetized and given endotoxin infusion during the 6 hours of the experiment. Eight pigs were randomized to the hydrocortisone group, receiving hydrocortisone at 5 mg/kg intravenously, or to the control group, receiving a corresponding volume of saline, as soon as the MPAP doubled the baseline value. P <0.05 was considered signiicant. Results No diference in baseline data was noted between the groups. No diferences in TNFα (Figure 1), IL-6 and core temperature were seen between the groups. Pigs in the hydrocortisone group had signiicantly higher mean arterial pressure and systemic vascular resistance index during the 6-hour experimental period than pigs in the control group, while heart rate was signiicantly lower in the hydrocortisone group at 1 to 6 hours as compared with controls. Conclusions Early treatment with hydrocortisone, administered after the onset of endotoxemia, counteracted circulatory deterioration, but did not afect the plasma levels of proinlammatory cytokines in this model. Thus, TNFα and IL-6 might not be involved in the development of circulatory dysfunction during the early phase of experimental endotoxemia. Figure 1 (abstract P18). TNFα over time (mean ± SEM). S8 P19 CD40L is selectively expressed on platelets from thrombocytopenic septic patients AM Montalbano1, F Turani2, EC Ciotti1, MF Fede1, MP Piperno1, PD David1, DF Fiume1, GC Caiazza1, SN Natoli1, FL Leonardis1, AB Bergamini1 1 University Tor Vergata, Rome, Italy; 2European Aurelia Hospital, Rome, Italy Critical Care 2010, 14(Suppl 1):P19 (doi: 10.1186/cc8251) Introduction It has been recently hypothesized that septic microangiopathy is caused or at least promoted by the interaction between endothelial surface receptor CD40 and its ligand CD40L, expressed by activated platelets. This interaction produces procoagulative changes in endothelial cells, endothelial apoptosis, subendothelial matrix exposition and microthrombi formation. Since virtually all septic patients show a certain degree of coagulation abnormalities, we hypothesized that low platelet count is associated with a diferent degree of CD40L expression and that this could correlate with the severity of disease. Methods To determine the inluence of sepsis on levels of platelet-derived CD40L expression, we performed a prospective observational study in a polyvalent university hospital ICU. Eighteen consecutively septic patients were enrolled in the study, independently of the platelet count and the severity of disease (SOFA score). Flow cytometry of fresh blood from septic patients (n = 18) and age-matched controls (n = 8) was performed for membrane-bound CD40L and CD62P on circulating platelets. Results Flow cytometry demonstrated low levels of CD62P in controls while the levels in patients were high. CD40L+ platelets were selectively found from patients with thrombocytopenia (platelet count ≤60,000/ mm3). Furthermore a direct correlation between CD40L expression and the SOFA score was found in patients with sepsis and thrombocytopenia compared to patients with sepsis without thrombocytopenia. Conclusions These results suggest that CD40L expression on platelets is somehow related to the degree of thrombocytopenia and possibly can be a marker of the severity of sepsis. Although the role of endothelialderived CD40/platelet-derived CD40L interaction is not fully understood during sepsis, the expression of CD40L on platelets could be related to the severity of organ disease due to the possible bursting of endothelial damage through this pathway. Further investigation is needed to determine whether platelets CD40L contributes to endothelial and subsequent organ damage, its role in thrombocytopenia and its correlation with the outcome of sepsis. The microvascular injury seems to be a central event in sepsis, so understanding the mechanisms underlying its development is crucial for the individuation of new and speciic therapeutic strategies. P20 Neuronal NOS-inhibition in the setting of septic cardiomyopathy A Van de Sandt1, R Windler1, A Gödecke2, J Ohlig3, S Becher1, T Rassaf1, J Schrader2, M Kelm1, M Merx1 1 Department of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Germany; 2Department of Cardiovascular Physiology, Heinrich-Heine-University, Düsseldorf, Germany; 3RWTH, Aachen, Germany Critical Care 2010, 14(Suppl 1):P20 (doi: 10.1186/cc8252) Introduction Nitric oxide (NO) plays a central role in the pathogenesis of sepsis. Recently, we demonstrated that endothelial NOS (eNOS) contributes to endogenous NO-production and modulates inlammation, associated with preserved cardiac function resulting in prolonged survival of eNOS–/– compared with wild-type (WT) mice. The role of neuronal NOS (nNOS) in septic cardiomyopathy remains unclear. This study’s aim is to elucidate the inluence of nNOS in the presence/absence of eNOS on cardiac function and survival in a clinically relevant model of sepsis. Methods Inhibition of nNOS was achieved via continuous application of the selective nNOS-inhibitor Vinyl-L-NIO (VL-NIO) (0.02 mg/kg BW/hour) using an osmotic mini pump. B6/c57 WT and eNOS–/– mice were rendered septic by cecum ligation and puncture (CLP). After 12 hours heart function was analyzed using a pressure–volume catheter placed in the left ventricle. For catecholamine responsiveness, norepinephrine was applied (0.4 μg/kg BW/minute, intraperitoneally). NOx-levels in plasma were measured using high-pressure performing liquid chromatography. Results Inhibition of nNOS via VL-NIO application resulted in signiicantly reduced nitrate plasma levels and prolonged survival (WT CLP + VL-NIO = 38 Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 hours vs WT CLP = 29 hours). However, cardiac function and norepinephrine responsiveness were not improved compared with untreated septic WT. In contrast to WT, application of VL-NIO in eNOS–/– had no inluence on plasma nitrate levels, while cardiac function and survival were signiicantly impaired compared with untreated septic eNOS–/–. Impaired cardiac function was accompanied by decreased survival time (eNOS–/– CLP + VL-NIO = 29.5 hours vs eNOS–/– CLP = 69.5 hours). Conclusions Pharmacologic inhibition of nNOS result in signiicant reduction of plasma nitrate levels and prolonged survival compared with untreated septic WT despite unimproved septic cardiomyopathy. In contrast, the signiicant survival beneit of septic eNOS–/– compared with septic WT was abrogated by pharmacologic nNOS inhibition. Furthermore, the latter developed severe septic cardiomyopathy. Whether eNOS acts as modulator of nNOS in this setting remains to be clariied by further studies. P21 Urinary albumin excretion is elevated in sepsis, but does not correlate with circulating VEGF-A levels S Basu1, M Bhattacharyya1, T Chatterjee2, S Todi1, A Majumdar1 1 AMRI Hospitals, Kolkata, India; 2Jadavpur University, Kolkata, India Critical Care 2010, 14(Suppl 1):P21 (doi: 10.1186/cc8253) Introduction In critically ill patients admitted with SIRS, endothelial dysfunction leads to increased capillary permeability. In the glomerulus, it manifests as increased albumin excretion. Microalbuminuria is a common inding in various acute conditions like sepsis, trauma and surgery. Studies have shown increased levels of vascular endothelial growth factor-A (VEGF-A), a potent vascular permeability inducing agent, in LPS-induced endotoxemia, severe sepsis and septic shock. The pathogenic mechanism of the glomerular leakage of albumin in acute inlammatory conditions remains to be clariied. We wished to investigate the causative role of VEGF-A, in this regard which might have therapeutic implications. Methods Prospective study in the 43-bed ICU of a tertiary care hospital. Of the consecutive patients admitted to the ICUs between September 2008 and January 2009, 597 patients were included, after excluding patients with ICU stay <24 hours, pregnancy, menstruation, anuria, hematuria and proteinuria due to renal and post- renal diseases. Of these, 30 consecutive patients with sepsis, severe sepsis and septic shock (sepsis group) and 30 randomly chosen patients without sepsis were recruited for the VEGF-A study. Spot urine samples for the albumin–creatinine ratio (ACR, mg/g) and serum for VEGF-A (ELISA) were collected on ICU admission. Correlation was analyzed using Spearman’s correlation coeicient. Results Sixty critically ill patients, with a median age (IQR) of 60 years (48 to 72), 39:21 male:female ratio, median APACHE II score (IQR) of 16 (7 to 23), and 3 median days of ICU stay, had a median ACR (IQR) of 125 mg/g (51.6 to 239.1) and a median VEGF-A (IQR) of 111 pg/ml (54.3 to 286.9) on ICU admission. The median ACR on admission in the sepsis group (n = 30) of 161.8 mg/g was signiicantly higher than the median ACR (78.3 mg/g) of the group without sepsis (n = 30) (P = 0.011). On statistical analysis, no signiicant correlation was obtained between levels of urinary ACR and serum VEGF-A (P = 0.327) in the entire group. Analysis for correlation between ACR and VEGF-A in the sepsis patients (P = 0.396) and in the group without sepsis (P = 0.518) yielded similar results. Conclusions Despite a strong physiologic rationale, our pilot study did not show an association between microalbuminuria and VEGF-A in critically ill patients. Larger studies are needed to come to a deinitive conclusion. P22 High mobility group box protein-1 preconditions isolated rat hearts and protects human pulmonary and renal cells against hypoxic injury CM Walshe, D O’Toole, B Higgins, JG Lafey, LG Kevin National University of Ireland, Galway, Ireland Critical Care 2010, 14(Suppl 1):P22 (doi: 10.1186/cc8254) Introduction High mobility group box protein-1 (HMGB) is released by activated monocytes/macrophages during sepsis. Levels correlated with mortality in patients and anti-HMGB antibodies prevented endotoxininduced death in animal models [1]. In marked contrast to these indings S9 are reports of cytoprotective efects because HMGB protected liver from ischemia/reperfusion (IR) [2] and HMGB-transgenic mice were resistant to myocardial infarction [3]. Despite these reports, little is known of the role or mechanism of HMGB. We aimed to further evaluate HMGB in rat hearts and in pulmonary and renal cell cultures. Methods Isolated hearts received HMGB/vehicle before 30 minutes ischemia and 120 minutes reperfusion. In separate studies, rats were rendered septic by caecal ligation and puncture (CLP) prior to IR. Left ventricular (LV) function was measured with a latex LV balloon. Infarct size was measured by TTC staining. For human cell culture studies, A549 alveolar cells or HK-2 renal tubular cells were treated with HMGB/vehicle before incubation in normoxia or hypoxia. Fluorimetric caspase-3 activity was used as measure of apoptosis. Cytochrome C was measured by ELISA. For HK-2 cells, the MTT assay was used to test viability. Results HMGB, prior to cardiac IR, preserved developed (d) LVP at 120 minutes reperfusion compared with controls (44 mmHg vs 27 mmHg, P <0.05) and infarct size, expressed as %V weight ± SEM, was reduced (31 ± 5.4 vs 44 ± 4.2, P <0.05), n = 6/group. Hearts from CLP rats had reduced baseline dLVP (59 mmHg ± 5.1 vs 97 ± 5.3, P <0.05) but infarct sizes after IR were signiicantly reduced (27 ± 8.8, P <0.05 vs 44 ± 6.2, P <0.05). In A549 cells, HMGB inhibited apoptosis (49% reduced caspase-3 activity (8.6 vs 17.1 a.u., P <0.01)). This was associated with reduced cytochrome C release (250 vs 389 pg/ml, P <0.05). Using MTT assay, HMGB protected against hypoxia-induced cell death vs controls (viability 75% vs 61%, P <0.05). Conclusions HMGB, or sepsis, similarly precondition the heart against IR injury. HMGB has anti-apoptotic efects that protect against hypoxic renal and alveolar cell injury. We conclude that HMGB has potent anti-ischemic efects in multiple organs and may function as an innate cytoprotective mediator in sepsis. References 1. 2. 3. Wang H, et al.: Science 1999, 285:248-251. Tsung A, et al.: J Exp Med 2005, 201:1135-1143. Kitahara T, et al.: Cardiovasc Res 2008, 80:40-46. P23 Early persisting elevation of plasma Pentraxin 3 is associated with mortality and with coagulation impairment in severe sepsis and septic shock A Coppadoro1, T Mauri1, G Bellani1, N Patroniti1, M Cugno2, A Grassi1, G Iapichino2, L Gattinoni2, A Mantovani2, A Pesenti1 1 Universita’ degli Studi di Milano-Bicocca, Monza, Italy; 2Universita’ degli Studi di Milano, Italy Critical Care 2010, 14(Suppl 1):P23 (doi: 10.1186/cc8255) Introduction Pentraxin 3 (PTX3) is an inlammatory mediator produced by a variety of tissue cells, like neutrophils, macrophages, myeloid dendritic, endothelial and epithelial cells [1]. During sepsis a massive inlammatory activation occurs, which often leads to an important coagulation system dysfunction. PTX3 upregulates coagulation promoters in vitro [2]. PTX3 may represent an early marker of severity and outcome and may be related to coagulation impairment in septic patients. Methods We studied 90 patients afected by severe sepsis or septic shock previously enrolled in a prospective trial regarding the impact of glycemic control on inlammation and coagulation. At enrollment we recorded sepsis signs, plasminogen activator inhibitor 1 (PAI-1, an inhibitor of ibrinolysis) activity and concentration, prothrombin fragments 1 + 2 (F1+2) concentration (a marker of coagulation activation), disease severity and organ dysfunctions. We measured plasma PTX3 levels at enrollment and everyday until day 7. Mortality was recorded at day 90. Results Although not diferent on day 1, PTX3 remained signiicantly higher in nonsurvivors than in survivors over the irst 5 days (P = 0.002 by general linear model). On day 1, septic shock patients had higher PTX3 levels than patients with severe sepsis (274.41 ± 321.92 vs 114.95 ± 129.93 ng/ml, P = 0.029, t test). Day 1 PTX3 was signiicantly correlated with SAPS II score (R2 = 0.08, P = 0.006, linear regression), platelets count (R2 = 0.14, P <0.001) and SOFA score (R2 = 0.16, P <0.001). Day 1 PTX3 was correlated with PAI-1 concentration (R2 = 0.211, P <0.001) and activity (R2 = 0.231, P <0.001) and with F1+2 concentration (R2 = 0.09, P = 0.045). Conclusions Persisting high levels of circulating PTX3 over the irst days from sepsis onset may be associated with mortality. PTX3 correlates with severity of sepsis and with sepsis-associated coagulation dysfunction. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 References 1. 2. Mauri T, et al.: Crit Care Med 2008, 36:2302-2308. Napoleone E, et al.: J Leukoc Biol 2004, 76:203-209. P24 Intravenous immunoglobulins prevent breakdown of the blood–brain barrier in experimental sepsis F Esen1, E Senturk1, P Ergin Ozcan1, B Ahishali1, N Arıcan1, N Orhan1, O Ekizoğlu2, D Ustek1, M Kucuk1, M Kaya1 1 Istanbul University Istanbul Medical Faculty, Istanbul, Turkey; 2Sadi Konuk Training and Research Hospital, Istanbul, Turkey Critical Care 2010, 14(Suppl 1):P24 (doi: 10.1186/cc8256) Introduction The efect of intravenous immunoglobulin preparations – immunoglobulin G (IgG), immunoglobulin G enriched with IgA and IgM (IgGAM) – on blood–brain barrier (BBB) integrity and survival rate was comparatively investigated in septic rats. Methods Sepsis was induced by cecal ligation and perforation (CLP) in Sprague–Dawley rats. The animals received either IgG (250 mg/kg, intravenously) or IgGAM (250 mg/kg, intravenously) 5 minutes before CLP surgery. All rats were observed for behavioral changes for 24 hours after CLP operation. To show the alterations in BBB integrity, Evans blue (EB; 69 kDa) dye extravasation was determined for quantitative measurement of BBB permeability, and horseradish peroxidase (HRP; 40 kDa) extravasation was evaluated to provide ultrastructural evidence for the transport pathways involved in BBB permeability. Immunohistochemistry was performed to show the alterations in immunoreactivity for tight junction protein occludin. Results A high mortality rate (34%) was noted in septic animals and the mortality rate was decreased to 15% and 3% by IgG and IgGAM, respectively. Both IgG and IgGAM alleviated the sickness behavior in septic rats and the animals were observed to be healthy and active. Increased extravasation of EB dye into brain tissue of septic animals was markedly decreased by both IgG and IgGAM. Occludin immunoreactivity remained essentially unchanged in all groups including CLP. In addition, strong staining for HRP was seen around vessels located in the cerebral cortex and the hippocampus in septic animals. Increased luminal and abluminal vesicles containing electron-dense HRP reaction product were noted in the cytoplasm of endothelial cells in the cerebral cortex and hippocampus of septic rats, emphasizing an increased BBB permeability predominantly by transendothelial route. In these animals, tight junctions were ultrastructurally intact suggesting that paracellular pathway of BBB is not responsible for the BBB breakdown in sepsis. Following IgG or IgGAM treatment, no ultrastructural evidence of leaky capillaries in brain was observed in septic animals indicating the blockade of the transcellular pathway. Conclusions The present study indicates that IgG and IgGAM improve the integrity of the BBB and inhibit CLP-induced sickness behavior in rats. P25 Early use of immunoglobulin in septic shock IC Cavazzuti, LR Rinaldi, LD Donno, SB Braccini, SB Busani, MG Girardis Policlinico di Modena, Italy Critical Care 2010, 14(Suppl 1):P25 (doi: 10.1186/cc8257) Introduction In addition to the interventions suggested by the guidelines of the Surviving Sepsis Campaign, in the recent years other therapeutic options have been proposed and tested for patients with severe sepsis and septic shock. Polyclonal intravenous immunoglobulins seem to be an interesting and useful option because of its activity in neutralizing endotoxin and in modulating the host immune response. In this retrospective study we assessed the efects of the early use of polyclonal intravenous immunoglobulins enriched with IgA-M (IgGAM) in addition to standard therapies on clinical outcome of patients with septic shock. Methods In January 2008, IgGAM was introduced into our ICU protocol for the management of septic shock patients (within 24 hours after shock appearance and at the dosage of 5 ml/kg for 3 days). From January 2008 S10 to September 2009, we studied 52 consecutive patients with septic shock admitted to our ICU. In each patient we recorded the SAPS II and SOFA scores, the compliance to the 6-hour and the 24-hour sepsis bundles, the compliance to IgGAM use, the length of stay in the ICU and the 30-day mortality rate. Results Due to low compliance of medical staf to protocol application, IgGAM has been used only in 27 patients (IgGAM group). At ICU admission, the severity scores were similar in patients with and without (Control group) IgGAM therapy (SAPS II: control 54 (22 to 99), IgGAM: 59 (39 to 101); P >0.05 and SOFA: control 9 (2 to 17); IgGAM 9 (4 to 15); P >0.05). The compliance to 6-hour and 24-hour bundles was also similar in the two groups, apart from compliance to luid therapy that was larger in the IgGAM group (85% vs 56% in Control group). The length of stay in the ICU was 15 ± 9 days in the IgGAM group and 18 ± 31 days in the Control group (P >0.05); the 30-day mortality was lower (P <0.05) in the IgGAM group (25%) than in the Control group (52%). Conclusions These preliminary data indicate that the early use of IgGAM, associated with interventions proposed by the SSC guidelines, reduces mortality of patients with septic shock. References 1. 2. Ballow M: Mechanism of action of intravenous immune serum globulin in autoimmune and inlammatory diseases. J Allergy Clin Immunol 1997, 100:151-157. Werdan K: Mirror, mirror on the wall, which is the fairest meta-analysis of all? Crit Care Med 2007, 35:2852-2854. P26 Low levels of immunoglobulin G in patients with sepsis or septic shock: a signum mali ominis? S Dietz, C Lautenschlaeger, U Mueller-Werdan, K Werdan University Clinics of the Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany Critical Care 2010, 14(Suppl 1):P26 (doi: 10.1186/cc8258) Introduction The role of intravenous immunoglobulin therapy in patients with sepsis and septic shock is still controversially discussed. In a retrospective analysis of the data from the SBITS-trial [1] we investigated whether the initial level of serum IgG on admission to the hospital in patients with sepsis and septic shock (before the irst administration of the irst dose of intravenous immunoglobulins) could be seen as a prognostic parameter for the primary outcome, lethality on day 28, or the secondary endpoints, lethality on day 7 or on the ICU. Methods A total of 543 were included in the trial: the patients were divided into four groups (quartiles) based on the 25th, 50th and 75th percentiles of their initial level of IgG on admission to the hospital. The irst group contained 140 patients with a range in the IgG serum level up to 6.1 g/dl. The second and third groups contained 134 patients and 136 patients, respectively, the immunoglobulin G levels were greater than 6.1 g/dl to 8.4 g/dl and greater than 8.4 g/dl to 11.9 g/dl. The fourth group containing 133 patients had IgG levels higher than 11.9 g/dl. In a logistic regression model we adjusted for potential confounders (that is, sex, age, APACHE II score, presence of shock on admission). Results On basis of this model we could show that lethality between the irst and second groups did not difer signiicantly with the lethality in the third (reference) group with physiologic levels of IgG on day 0. Surprisingly the lethality of the fourth group, with IgG levels higher than 11.9 g/dl, was signiicantly higher compared with the reference quartile (OR 1.69, CI 1.01 to 2.81, P = 0.047). Conclusions Our post-hoc analysis did show no prognostic relevance of a low level of serum IgG on admission to hospital for the 543 patients with sepsis and septic shock. Thus the initial serum level of IgG seems to be of no aid in making the decision to initiate therapy with intravenous immunoglobulins for these patients. Whether a high level of serum IgG on admission is an independent risk factor for an increased lethality in critically ill patients, as shown in our analysis, needs to be investigated in further studies. Reference 1. Werdan K, et al.: Score-based immunoglobulin G therapy of patients with sepsis: the SBITS study. Crit Care Med 2007, 35:2693-2701. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P27 Background factors in patients receiving immunoglobulin administration and changes in sepsis markers T Ikeda1, K Ikeda1, H Taniuchi1, S Suda1, Y Takahashi2 1 Tokyo Medical University, Hachioji Medical Center, Tokyo, Japan; 2Sannoudai Hospital, Ibaraki, Japan Critical Care 2010, 14(Suppl 1):P27 (doi: 10.1186/cc8259) Introduction The potentially envisaged actions of intravenous immunoglobulin (IVIg) on severe infectious disease include virus or toxin neutralizing action, opsonic efect, complement bacteriolytic activity, and enhancement of sensitivity to antibiotics. In the case of severe infectious disease, antibiotics are often supplemented with administration of IVIg. The aim of this study is that the changes in sepsis markers followed by IVIg administration are investigated with severe sepsis or severe septic shock patients. Methods The subjects were 52 patients admitted to an ICU with a diagnosis of severe sepsis or septic shock and from whom informed consent had been obtained for the present study. IVIg was administered intravenously for 3 days (5.0 g/day) and measurements were undertaken before administration (Day 1), on the day after completion of administration (Day 4), and on Day 7. The items measured were IL-6, C-reactive protein (CRP) and, as indices of vascular endothelial cell activation, plasminogen activator inhibitor-1 (PAI-1) and adhesion molecules (endothelial leukocyte adhesion molecule-1 (ELAM-1)); the efect of IVIg administration on these markers was then studied. The IVIg studied was polyethylene glycol-treated human immunoglobulin injection luid (2.5 g, 50 ml, one vial). Results The APACHE II score was 25.3 ± 7.8, the SOFA score 9.5 ± 3.5, and the survival rate after 28 days 76.9%. The values before IVIg administration were: procalcitonin 28.8 ± 44.5 (median value 13.6) ng/ml, CRP 16.3 ± 8.3 (median value 16.0) mg/dl, IL-6 8,873 ± 19,362 (median value 744) pg/ml, PAI-1 374 ± 428 (median value 178) ng/ml, and ELAM-1 198 ± 359 (median value 61) ng/ml. All values were thus elevated. After the completion of IVIg administration, the level of mediators other than ELAM-1 (procalcitonin, CRP, IL-6, PAI-1) decreased signiicantly. Conclusions The results of the present study found signiicant decreases of IL-6 and PAI-1 resulting from immunoglobulin administration, but did not indicate a protective efect on vascular endothelial cell function. P28 C1-esterase inhibitor (C1INH) implication in systemic inlammation in sepsis A Igonin, N Lazareva, VY Uvarov BioGenius Research Centre, Moscow, Russia Federation Critical Care 2010, 14(Suppl 1):P28 (doi: 10.1186/cc8260) Introduction C1INH is the most potent endogenous regulator of compliment as well as intrinsic coagulation pathways and the kallekrein–kinin system. S11 Methods C1INH systemic activity was studied in patients who were enrolled within 48 hours after onset of sepsis (ACCP, 1992). The analysis of C1INH activity in quartiles (Q) was conducted in terms of RCT of human puriied C1INH (Bicizar, Russia). Results Sepsis patients (n = 40) responded with an increase of C1INH activity in comparison with healthy individuals (Figure 1). Thirty percent of Q1 patients had ARDS and septic shock whereas in Q4 everyone showed only signs of sepsis. The CRP level was higher in Q1 patients (243.4 ± 39.9 mg/l) than in Q4 (144.0 ± 20.07 mg/l; P = 0.04), whereas the C4 subunit was lower in Q1 (0.19 ± 0.04 g/l) than in Q4 (0.32 ± 0.04 g/l; P = 0.05). Conclusions Inability to upregulate C1INH activity in sepsis was associated with enhanced systemic inlammation, higher number of ARDS and septic shock cases. P29 Prognostic value of B-type natriuretic peptide in critically ill patients with new onset of fever: preliminary study V Soulountsi1, V Voutsas1, P Kontou1, A Giakamozis1, K Hatzimanolis2, T Lazaridis1, V Hatsiou2, M Mpitzani1 1 ICU, G. Papanicolaou, Thessaloniki, Greece; 2Microbiology Laboratory, G. Papanicolaou Hospital, Thessaloniki, Greece Critical Care 2010, 14(Suppl 1):P29 (doi: 10.1186/cc8261) Introduction The purpose of the study is the evaluation of B-type natriuretic peptide (BNP) as a predictor of septic complications and ICU mortality in patients with a new onset of fever during the irst 3 days of hospitalization in the ICU. Methods Thirty-one ICU patients (21 males and 10 females) with new onset of fever and leukocytosis within the irst 3 days of ICU admission were prospectively included in the study. Exclusion criteria were heart or renal failure, chronic obstructive pulmonary disease and head trauma. Serial plasma samples were taken on days 1, 2 and 4 after the onset of fever for BNP level measurement. BNP values were correlated with severity scores (Acute Physiology and Chronic Health Evaluation (APACHE II) and Sequential Organ Failure Assessment (SOFA)), the progression to septic shock and the inal outcome. Results According to the clinical and laboratory indings within the irst 3 days of hospitalization, the patients included in the study were divided into three groups: Group A = systemic inlammatory response syndrome (SIRS) (seven patients), Group B = sepsis (14 patients) and Group C = septic shock (10 patients). The BNP value on days 1 and 2 was signiicantly associated with the SOFA Max value (P <0.001). The BNP value on day 4 was signiicantly associated with ICU mortality (P = 0.006). The optimal cutof BNP value for diferentiating between nonsurvivors and survivors was estimated to be 203.55 pg/ml (sensitivity = 100%, speciicity = 61.1%). In Group B patients, BNP value on day 2 was signiicantly higher in patients who inally progressed to septic shock (P = 0.001). The optimal cutof BNP value for identifying these patients was estimated to be 212.45 pg/ml (sensitivity = 85.7%, speciicity = 64.3%). Conclusions In ICU patients with new onset of fever during the irst 3 days of ICU hospitalization, the BNP value on day 4 seems to be a good predictor of ICU mortality. In patients with sepsis, a cut-of BNP value of 212.45 pg/ml on day 2 could be a predictor of progression to septic shock. Due to the small number of patients included in our study, further studies are needed to conirm these indings. P30 Microalbuminuria evaluated as a biomarker in patients with septic shock C Grion, L Cardoso, C Carrilho, J Altain, S Barros, L Carvalho, J Festti, F Mansano, T Okamoto, K Uehara, J Dias, GC Silva Hospital Universitário de Londrina, Brazil Critical Care 2010, 14(Suppl 1):P30 (doi: 10.1186/cc8262) Figure 1 (abstract P28). C1INH activity in patients with sepsis analyzed in quartiles (Q1, Q2, Q3, Q4) in comparison with healthy individuals. Introduction The level of microalbuminuria is thought to relect the severity of inlammation during acute phase response and may have prognostic value with regard to survival. This study aimed to describe urinary albumin excretion in patients with septic shock and changes in microalbuminuria levels in the irst 3 days of treatment. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Methods Prospective observational study of 49 consecutive patients with septic shock admitted to a general ICU. During the irst 24 hours after severe sepsis was diagnosed, we collected data to calculate APACHE II and SOFA scores and urinary sample to measure urinary albumin. Another sample of urine was collected on the third day of septic shock. Microalbuminuria was measured by immunoturbidimetry with a limit of detection of 3.5 mg/l. The study was approved by the local Ethic Committee. Results The mean age was 65.8 ± 15 years and male sex was more frequent (63.3%). Pneumonia (59.2%) was the most common source of sepsis. Mean APACHE II and SOFA scores on the irst day of sepsis were 24.4 ± 7.7 and 8.7 ± 3.7, respectively. Observed mortality was 71.4%. Median urinary albumin was 7.0 mg/l (IQT: 4.7 to 60.3 mg/l) for survivors and 15.5 mg/l (IQT: 7.9 to 77.1 mg/l) for nonsurvivors on the irst day of septic shock. Urinary albumin decreased from 7.0 mg/l (IQT: 4.7 to 60.3 mg/l) to 3.9 mg/l (IQT: 3.6 to 44.1 mg/l) in survivors during the irst 3 days of septic shock, and in nonsurvivors remained at the same level from 15.5 mg/l (IQT: 7.9 to 77.1 mg/l) to 14.5 mg/l (IQT: 3.9 to 45.3 mg/l) in the period of observation. Conclusions Patients with septic shock showed high frequency of microalbuminuria. Levels of urinary albumin showed a tendency to decrease in survivors, suggesting prognostic signiicance. References 1. 2. Thorevska N, et al.: Crit Care Med 2003, 31:1075-1081. Abid O, et al.: Chest 2001, 120:1984-1988. P31 Evaluation of automated hematologic VCS parameters in severe sepsis and septic shock: a case–control study A Cortegiani1, A Di Benedetto1, L Marino1, G Virga1, R Chiaramonte1, C Sarno2, SM Raineri1, A Giarratano1 1 University of Palermo, Italy; 2Fondazione Istituto S. Rafaele, Cefalù (PA), Italy Critical Care 2010, 14(Suppl 1):P31 (doi: 10.1186/cc8263) Introduction A cheap and quick hematologic diagnostic parameter for detection of sepsis would have both economic and therapeutic beneits. The Coulter LH series hematology analyzer uses the VCS technology (Volume, Conductivity, Laser Scatter) providing information about cell volume, size, internal structure, and surface morphology. Many authors analyzed the clinical usefulness of VCS parameters in reactive neutrophils for detection of sepsis. An increase in mean cell volume and a decrease in mean light scatter in septic patients have been described. Our aim is to verify the correlation between VCS parameters and sepsis. Methods We enrolled 92 patients admitted in our ICU and divided them into two groups: Controls (48) and Sepsis (44). We collected blood samples immediately after making the diagnosis. All samples were analyzed by Coulter LH 500 hematology analyzer. We realized ROC curves for each V, C, S parameter. Results The AUC was 0.816 (95% CI, 0.722 to 0.889) for mean-V value; 0.546 (95% CI, 0.439 to 0.650) for mean-C value; 0.604 (95% CI, 0.497 to 0.704) for mean S value (Figure 1). The correlation with sepsis was a linear positive one for mean-V (strong) and mean-C (weak) instead of a linear negative one for mean-S. The best cut-of value for mean-V was >163 (Sens: 84.09%; Figure 1 (abstract P31). S12 Spec: 68.75%); >137 for mean-C (Sens: 72.73%; Spec: 41.67%); <134 for mean-S (Sens: 56.82%; Spec: 64.58%). Conclusions Our study shows the high diagnostic performance of mean-V and the weak one of mean-C and mean-S in septic patients. The clinical usefulness of mean-V is strengthened by the quickness and cheapness of its analysis. It could be tested daily or more as a valid laboratorial help for critical patient’s clinical assessment. P32 Use of CD64 for the diagnosis of sepsis: a case–control study A Cortegiani1, L Marino1, A Di Benedetto1, G Virga1, G Evangelico1, C Sarno2, SM Raineri1 1 University of Palermo, Italy; 2Fondazione Istituto S. Rafaele, Cefalù (PA), Italy Critical Care 2010, 14(Suppl 1):P32 (doi: 10.1186/cc8264) Introduction CD64 is the high-ainity receptor of IgG. It is upregulated by inlammatory cytokines on neutrophils. The upregulation of CD64 is linked with PMN activation in SIRS or sepsis. Our aim is to verify these correlations. Methods We enrolled 48 ICU critical patients and three groups were created: SIRS– (17), SIRS+ (13), Sepsis (17). We evaluated CD64 X-mean values among the three groups as shown in Figure 1. We used a t test to check the correlation between uprising CD64 and diferent groups. We veriied the correlation CD64/SOFA (Figure 2), WBC, NE, and patients’ age using r. Results We found a CD64 higher level in sepsis compared with SIRS– (t = 8.095; P <0.001) and with SIRS+ (t = 4.938; P <0.001). There were a high positive linear correlation between CD64 and SOFA score (r = 0.806; Figure 1 (abstract P32). Figure 2 (abstract P32). Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P <0.0001), a weak linear positive one with WBC count, a weak linear positive correlation with NE count; no correlation with age. Conclusions Our study shows that CD64 can identify SIRS/sepsis. We found a correlation between CD64/SOFA; no inluence of WBC, NE and age was detected. P33 Endotoxin assay with endotoxin scattering photometry is one of the diagnostic markers of sepsis Y Kase1, T Obata2 1 Jikei University School of Medicine, Tokyo, Japan; 2Microbial Chemistry Research Foundation, Tokyo, Japan Critical Care 2010, 14(Suppl 1):P33 (doi: 10.1186/cc8265) Introduction Endotoxin scattering photometry (ESP) is one of a newly developed clinically applicable method for endotoxin assay. Although ESP is an analogous assay of turbidimetric method, it enables one to detect very small amounts of endotoxin within 1 hour. This is because ESP can directly detect clotting enzyme product, coagulin, which is the irst appearance of Limulus amebocyte lysate (LAL) cascade and the precursor of gel clots. Methods To study the correlates and prognostic signiicance of the endotoxin assay with ESP, we enrolled a total of 80 people consisting of three groups which were normal healthy volunteers (n = 35), patients admitted to the emergency department (ED) (n = 21) and patients admitted to the ICU (n = 24). To examine whether endotoxin is inluencing in the severity of disease, we used sepsis/SIRS stratiication which was deined by the American College of Chest Physicians/Society of Critical Care Medicine (ACCP/SCCM). Results Of all 80 people, 33.7% (n = 27) was sepsis. The levels of endotoxin were signiicantly higher in the patients with sepsis (median, 18.4 pg/ml; interquartile range, 3 to 54.1 pg/ml) than in the people without sepsis (0.227 pg/ml; 0.031 to 0.493 pg/ml). The area under the receiver operating characteristic curve was 0.951 in the patients with sepsis. Cut-of concentrations for optimum prediction of sepsis with ESP were endotoxin >7.06 pg/ml (diagnostic eiciency: 92.6%). Conclusions Endotoxin assay with ESP is one of the diagnostic markers of sepsis because the levels of endotoxin in patient with sepsis are clearly high. Endotoxin assay with ESP concentration higher than 7.06 pg/ml indicates sepsis. References 1. Obata T, Nomura M, Kase Y, Sasaki H, Shirasawa Y: Early detection of the Limulus amebocyte lysate reaction evoked by endotoxins. Anal Biochem 2008, 373:281-286. P34 Immature platelet fraction as predictive index of sepsis C Scaramucci, R De Blasi, S Tribuzi, A Carlini II Faculty of Medicine – University of Rome ‘La Sapienza’ S. Andrea, Rome, Italy Critical Care 2010, 14(Suppl 1):P34 (doi: 10.1186/cc8266) Introduction The incidence of sepsis is reported around 37% in European ICUs [1]. The mortality rate depends on the severity of organ failure, up to 65% if four or more organs are involved. Multiple organ failure (MOF) is due to microcirculatory dysfunction with microthrombosis resulting from coagulation disorders including platelets’ activation. An early diagnosis should identify the microcirculatory dysfunction before MOF became clinically evident. The diagnosis of sepsis is commonly based on clinical criteria, pathogen identiication and use of markers like procalcitonin (PCT) and C-reactive protein (PCR) associated with infection. The aim of our study is to evaluate whether the routine measurement of immature platelet fraction (IPF), considered a precocious marker of platelet production, is associated with sepsis and its severity and/or whether it could be used as a predicting marker of sepsis. Methods We enrolled 66 consecutive patients admitted to the ICU, dividing them into two groups: septic (n = 44) and no septic (n = 22). The severity of sepsis was evaluated. The exclusion criterion was a platelet count <150,000/mm3. Blood count, coagulation, PCR, PCT, and IPF were collected every day. Results The IPF values between septic (4.6 ± 3.1) and no septic patients (3.3 ± 1.5) did not difer (P = 0.16). No correlation was found between IPF S13 Table 1 (abstract P34) IPF (%) PCT (ng/ml) PCR (mg/dl) No sepsis Sepsis Mann–Whitney 5.4 ± 2.9 0.68 ± 1.1 9.57 ± 10.2 3.3 ± 1.5 0.57 ± 1.3 11.7 ± 10 P = 0.04 P = 0.4 P = 0.46 values and the severity of septic condition (no sepsis 11.7 ± 10.1; sepsis 14.3 ± 10.5; severe sepsis 10.5 ± 9.1; septic shock 19.5 ± 12.4; P = 0.3). When we considered only subjects who did not have sepsis at the ICU admission we found that patients who developed sepsis during the recovery had IPF values higher than patients who did not develop sepsis (Table 1). Conclusions From our results IPF cannot be considered a marker of sepsis. Conversely it could be used as predictive index of sepsis because it can identify patients who will develop sepsis. References 1. Vincent et al.: Sepsis in European intensive care units: results of the SOAP study. Intensive Care Med 2006, 34:344-353. P35 Serial estimation of cytokine markers and their correlation with mortality in elderly patients with sepsis R Bhanot, J Kaur, M Rao, T Ramachandran, K George, D Veliath Pondicherry Institute of Medical Sciences, Pondicherry, India Critical Care 2010, 14(Suppl 1):P35 (doi: 10.1186/cc8267) Introduction Sepsis is a serious health problem in the elderly with a high degree of mortality. The study of pathophysiology of sepsis has lead to the development of cytokine markers which help in establishing diagnosis, quantifying the severity and assessing the response to therapy. TNFα and IL-6, a pleotropic cytokine, are among the most well-studied proinlammatory cytokines in sepsis. However, very limited data are available in elderly subjects regarding the markers for sepsis. The present study was undertaken to establish the cytokine proile in sepsis in the elderly and develop markers for prediction. The inluence of gender on cytokine production and mortality in elderly patients with sepsis was considered in particular. Methods In this prospective study, 50 elderly patients, age above 65 years, satisfying the systemic inlammatory response syndrome (SIRS) criteria were included. Serial estimations of TNFα and IL-6 were done on days 1, 3 and 7 of ICU admission. Results The results were drawn on the basis of gender and survival. A correlation of APACHE score, TNFα values and IL-6 values on day 1, day 3 and day 7 between survivors and nonsurvivors was also documented, which showed reducing levels of IL-6 levels from days 1 to 7 in the survivor group (P <0.01). The TNFα level was signiicantly low on day 1 in the nonsurvivor female group (P <0.00001). Conclusions Cytokine proiling for TNFαand IL-6 level in elderly patients with sepsis helps in prognosticating the outcome. Female gender was an independent predictor of increased morality in critically ill patients with documented infection. References 1. 2. 3. Martin GS, et al.: Crit Care Med 2006, 34:15-21. Ulloa L, et al.: Trends Mol Med 2005, 11:56-63. Oberholzer A, et al.: Shock 2005, 23:488-493. P36 Inluence of TIMP-1/MMP-9 ratio on the severity and mortality in sepsis L Lorente1, M Martín2, J Solé-Violán3, J Blanquer4, L Labarta5, C Díaz6, J Borreguero1, J Páramo7 1 Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain; 2Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain; 3 Hospital Universitario Dr Negrín, Las Palmas de Gran Canaria, Spain; 4 Hospital Clínico Universitario de Valencia, Spain; 5Hospital San Jorge de Huesca, Spain; 6Hospital Insular, Las Palmas de Gran Canaria, Spain; 7 CIMA-University of Navarra, Pamplona, Spain Critical Care 2010, 14(Suppl 1):P36 (doi: 10.1186/cc8268) Introduction The role of matrix metalloproteinases (MMPs) and tissue inhibitors of matrix metalloproteinases (TIMPs) in sepsis remains unclear. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S14 Previously reported have been higher circulating levels of TIMP-1 in septic patients than in controls [1], higher PAI-1 levels in nonsurviving than in surviving septic patients [2], and a positive correlation between TIMP-1 and PAI-1 in apparently healthy adult individuals [3]. The objective of this study was to determine the association between TIMP-1/MMP-9 ratio and PAI-1, and its inluence on the severity and mortality of patients with sepsis. Methods This was a multicenter, observational and prospective study carried out in six Spanish ICUs. We included 192 (125 surviving and 67 nonsurviving) patients with severe sepsis. Serum levels of MMP-9, TIMP-1 and plasma levels of PAI-1 were measured at the time of diagnosis. Results Nonsurviving septic patients presented higher levels of TIMP-1 (P <0.001), higher TIMP-1/MMP-9 ratio (P <0.001), higher levels of PAI-1 (P <0.001), higher SOFA score (P <0.001), higher lactic acid levels (P <0.001) and lower platelet count (P <0.001) than surviving ones. TIMP-1/MMP-9 ratio positively correlated with PAI-1(P <0.001), lactic acid levels (P <0.001), SOFA score (P <0.001), INR ratio (P <0.001), aPTT (P <0.001), and negatively with platelet count (P <0.001). The mortality prediction by TIMP-1/MMP-9 ratio (AUC = 0.66; 95% CI = 0.58 to 0.74; P <0.001) was similar to that provided by other markers of severity such as lactic acid (AUC = 0.67; 95% CI = 0.58 to 0.75; P <0.001) and SOFA score (AUC = 0.71; 95% CI = 0.64 to 0.79; P <0.001). Conclusions The TIMP-1/MMP-9 ratio may be of great pathophysiological signiicance in terms of severity and mortality in sepsis, and may represent a biomarker to predict the clinical outcome of septic patients. The novel inding of our study is the association between TIMP-1/MMP-9 ratio and PAI-1 levels in sepsis, which can contribute in the organ dysfunction and mortality of sepsis. Acknowledgements Study supported, in part, by the grants FUNCISPI-42/07 and GTEI-SEMICYUC-2009. References 1. 2. 3. Figure 1 (abstract P37). SOFA adults. Solid line, SOFA 0 to 12; dashed line, SOFA 13 to 24. Hofmann U, et al.: Scand J Infect 2006, 38:867-872. Hermans PW, et al.: Lancet 1999, 354:556-560. Aznaouridis K, et al.: Atherosclerosis 2007, 195:212-215. P37 Cytokine response in severe sepsis: predicting and modelling the course of illness J Malaska1, M Kratochvil2, M Kyr2, P Jabandziev2, F Otevrel2, K Muriova2, M Fedora2, V Sramek3, J Michalek2, P Sevcik2 1 University Hospital Brno, Czech Republic; 2University Hospital Brno and Faculty of Medicine Masaryk University, Brno, Czech Republic; 3St Anne’s University Hospital Brno and Faculty of Medicine Masaryk University, Brno, Czech Republic Critical Care 2010, 14(Suppl 1):P37 (doi: 10.1186/cc8269) Introduction Severe sepsis remains one of the most threatening conditions in intensive care. During the progression of sepsis from early hit to multiorgan failure proinlammatory and anti-inlammatory cytokines are released. Cytokines can be used as biomarkers to determine the speciic patterns of sepsis progression and association with mortality [1]. These biomarkers were successfully used as predictors in animal studies [2]. Data from humans, especially comparison between children and adults, are limited. Hence, in this study we widely describe systemic cytokine response in this type of patient population. Methods Prospective study of 37 subjects (20 children, 17 adults) hospitalized with severe sepsis in intensive care. We measured CRP, procalcitonin, TNF, IL-1β, IL-4, IL-6, IL-8, IL-10, IL-12, TREM-1. ANOVA models were speciied using Proc Mixed. Study was fully approved by an ethics committee. Results We identiied a correlation of CRP levels with mortality or presence of shock (Figure 1). We found a distinct feature of CRP in adults with pronounced dynamic dichotomy in these subjects. Levels of IL-6 were signiicantly diferent in adult patients in the context of shock states. High IL-6 levels in the beginning of sepsis were associated with shock during progression of illness. Highest risk of death was in adult patients associated with TREM-1 sustained high after 48 hours after sepsis onset (Figure 2). Otherwise, there was no correlation with death, shock states and SOFA score for PCT, TNF, IL-1β, IL-4, IL-8, IL-10, and IL-12. Conclusions Response of circulating factors in patients with severe sepsis is heterogeneous in the adult and children population and has some distinct features according to the dynamics of CRP, IL-6 and TREM-1. Figure 2 (abstract P37). Adults. Solid line, exitus; dashed line, survived. Acknowledgements Supported in part by the Internal Grant Agency of the Ministry of Health NR 9297-3 and NR 9894-4. References 1. 2. Kellum JA, et al.: Arch Int Med 2007, 167:1655-1663. Osuchowski et al.: Crit Care Med 2009, 37:1567-1573. P38 Time course of IL-6 and LBP, candidate biomarkers of sepsis in surgical critical care E Kipnis, L Ogé, B Soudan, B Leroy, B Vallet, G Lebufe Centre Hospitalier Régional Universitaire de Lille, France Critical Care 2010, 14(Suppl 1):P38 (doi: 10.1186/cc8270) Introduction The outcome of sepsis in critically ill patients relies on rapid identiication and therapy. However, identiication of sepsis in these patients is challenging, and focus has shifted towards biological surrogates as diagnostic/therapeutic biomarkers. IL-6 and lipopolysaccharide binding protein (LBP) may have such a potential. Methods Retrospective analysis of daily IL-6 and LBP serum levels over the course of a 3-month laboratory feasibility study of large-scale chemiluminescent immunometric assays on unused residuals of routine patient blood samples from the surgical critical care unit. We determined the time course of IL-6 and LBP over septic events deined as 4 days before and after the initiation of antimicrobial therapy as day 0 (n = 40). Variations over time of IL-6 and LBP in both absolute values and amplitude were measured between day –4 to day 0 and day 0 to day +4. Candidate biomarker variations were assessed for coherence with clinical evolution of sepsis to determine biomarker-like behavior. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S15 Results Only amplitudes of variation were coherent with clinical evolution of sepsis rather than variations in absolute values or values relative to published thresholds. Coherence between patient evolution and biomarker time course was 93% for IL-6 and 85% for LBP. IL-6 levels always increased to over at least 50% of baseline (51 to 2,523%) before initiation of antibiotics. IL-6 decreased by at least 45% (45 to 98%) of the maximal value when sepsis resolved successfully with antimicrobial therapy in 92% of the cases. Stagnating IL-6 levels always paralleled absence of resolution of sepsis. No pre-antimicrobial initiation increase of LBP was observed. LBP always decreased by at least 16% (16 to 85%) of the maximal value when sepsis resolved successfully with antimicrobial therapy. LBP increase after initiation of antimicrobials or LBP stagnation paralleled absence of clinical resolution. Concordant patterns of both IL-6 and LBP were always coherent with clinical evolution but only concerned 35% of the cases. Conclusions IL-6 and LBP behave as biomarkers over the course of sepsis in surgical critical care patients. Only dynamic monitoring may yield any information relevant to diagnosis or treatment follow-up. It remains to be shown how well these biomarkers perform through other study designs. Figure 1 (abstract P40). CRP and complications in all groups. P39 Prognostic value of melatonin in patients with sepsis: a comparison of survivors and nonsurvivors K Alan, D Memis, G Altun, N Sut Trakya University, Edirne, Turkey Critical Care 2010, 14(Suppl 1):P39 (doi: 10.1186/cc8271) Introduction Our objective was to investigate the plasma levels of melatonin and the prognostic value of these markers in patients with sepsis. This is a prospective study of 131 patients over 22 years old with sepsis in the ICU. Methods The patients were divided into two groups containing 72 patients as survivors (Group I) and 59 patients as nonsurvivors (Group II). The blood collection was performed in the night (02.00 to 04.00 hours) and the Acute Physiologic and Chronic Health Evaluation II (APACHE II) score calculated on the day of hospitalisation, second day and the last day (discharge or death). The samples were centrifuged methodically and plasma samples were preserved at –200°C. After reaching the target quantity, all plasma samples were studied with RIA method at room temperature. Results Statistically signiicant high APACHE II values were determined in Group II compared with Group I on the all days (P <0.05). Statistically signiicant low nocturnal plasma melatonin values were determined in Group II compared with Group I on the last day (P <0.05). In Group II, duration of mechanical ventilation and stay of ICU are longer, and at the last days of biochemistry parameters failed (elevation of urea, creatinine, serum glutamic oxaloacetic transaminase and serum glutamic pyruvic transaminase) (P <0.05). Conclusions We conclude that from plasma melatonin values it is impossible to predict the prognosis but during the follow-up these values can demonstrate the status of prognosis in septic patients. There are several factors afecting these melatonin values; thereby we propose that further research should be performed. P40 Serum C-reactive protein as a prognostic variable in elective surgery ICU patients: especially valuable following esophagectomy M Van Genderen, H De Geus, D Gommers, J Van Bommel Erasmus MC, Rotterdam, the Netherlands Critical Care 2010, 14(Suppl 1):P40 (doi: 10.1186/cc8272) Introduction Serum C-reactive protein (CRP) is synthesized in response to inlammatory status. Elevated CRP levels are associated with an increased risk of multiorgan failure in ICU patients. Preoperative elevation of serum CRP is a prognostic indicator in gastric and colorectal surgery. The aim of this study was to determine serum CRP as prognostic variable in patients undergoing esophagectomy with gastric tube reconstruction in contrast to other ICU admitted patients. Methods Data were collected retrospectively for a total of 208 patients admitted to the ICU following elective surgery from October 2007 to December 2008. Patients included underwent esophagectomy with gastric tube reconstruction, liver transplantation, hemihepatectomy, neuro- and abdominal aneurysm surgery. Postoperative serum markers were measured and the relation between the course of postoperative serum CRP, development of complications and prognosis of the patients was investigated. Results Postoperative serum CRP was signiicantly higher at T24 in patients undergoing esophagectomy with gastric tube reconstruction, compared with all other patients. Higher serum CRP levels correlated with the occurrence of complications in the heterogeneous ICU population but especially in the esophagectomy patients. Within this group, serum CRP levels at T24 and T48 were signiicantly higher in patients with a postoperative pneumonia, which in itself was associated with increased 1-year mortality. Conclusions Postoperative serum CRP levels can easily be monitored in the ICU in order to identify patients at risk for the development of postoperative complications. Especially in the esophagectomy patients, the occurrence of postoperative complications is associated with reduced survival. P41 Role of procalcitonin as a diagnostic and prognostic marker of infectious diseases in the emergency department: preliminary data L Magrini, V Mura, F Travaglino, O Piras, E Ferri, S Di Somma A. O. S.Andrea, Rome, Italy Critical Care 2010, 14(Suppl 1):P41 (doi: 10.1186/cc8273) Introduction An observational study was conducted in a teaching hospital to evaluate the diagnostic and prognostic value of procalcitonin together with C-reactive protein (CRP) in assessing the presence of infection/sepsis in patients arriving in the emergency department (ED). The objective was to improve diagnostic and therapeutic time to intervention by the emergency physician. Methods Three hundred and ive patients were studied (145 male, 160 female, mean age 67.2 years). Vital parameters were recorded during patient’s stay in the ED. Hemocultures and biological luids cultures were performed before antibiotic therapy. CRP and procalcitonin were performed at arrival in the ED, and after 5 days of antibiotic therapy. Results Median PCT and CRP values at arrival in the ED were 0.3 ng/ml and 12.9 mg/dl, after 5 days they were 0.09 ng/ml and 4.2 mg/dl with a signiicant statistical diference in both markers (P <0.001). PCT was higher in sepsis vs infections (respiratory, urinary, gut or skin infections) (3.1 vs 0.2 ng/ml, P <0.001). PCT pre-therapy was signiicantly higher in septic nonsurvivors vs septic survivors (1.0 vs 0.2 ng/ml, P <0.001), and there was a signiicant PCT increase after 5 days in nonsurvivors vs survivors (3.6 vs 0.07 ng/ml) (P <0.001). CRP results did not show a statistical signiicance, except for CRP measured after 5 days (3 mg/dl) vs CRP pre-therapy in survivors (12 mg/dl, P <0.001). PCT (cut-of 0.5 ng/ml) ROC curve showed an AUC 0.72 (P <0.001), with a sensitivity 75% as a diagnostic marker for Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S16 Figure 1 (abstract P42). Example 1 (left): sepsis secondary to hydronephrosis. This graph clearly shows the rise in procalcitonin (PCT) during early onset of sepsis and its fall during antibiotic treatment. Antibiotics were discontinued when the PCT level fell to 80% of its peak value on day 8. Example 2 (right): laparoscopic cholecystectomy complicated by bile peritonitis. Good response to antibiotics initially, but PCT started to rise on day 12 which prompted us to change antibiotics. Serial PCT is useful to assess the response to treatment. infection. In septic patients, PCT ROC curve had an AUC 0.70 (P <0.001) if considered as a prognostic factor of death (cut-of 1 ng/ml). Although pre-therapy PCT values were not particularly sensitive, nor speciic for predicting deaths, PCT in therapy (cut-of 0.5 ng/ml) had an AUC 0.79 (sensitivity 75%, speciicity 76% in predicting events) (P <0.0001). This was higher than CRP (AUC 0.73, P <0.0004). Conclusions PCT, with CRP, is useful to make an initial rapid infection diagnosis for patients presenting to the ED, and also to discriminate it from sepsis. Our results are in agreement with other authors [1,2]. A PCT cut-of value of 0.5 ng/ml shows high sensitivity as a diagnostic infection marker, but also as a prognostic marker for outcomes. PCT with CRP are useful tools to assess a fast empiric therapy, and to ameliorate the prognosis of infectious/septic in ED patients. References 1. 2. Hausfater P, et al.: Clin Infect Dis 2002, 34:895-901. Balci C, et al.: Crit Care 2003, 7:85-90. P42 Evaluation of procalcitonin at James Paget Intensive Care Unit A Brodbeck, N Elumogo, G Rajendran James Paget University Hospital NHS Foundation Trust, Great Yarmouth, UK Critical Care 2010, 14(Suppl 1):P42 (doi: 10.1186/cc8274) Introduction Procalcitonin (PCT) ofers the possibility of diferentiating bacterial infection from viral or non-infectious reactions. PCT can be used to support decision-making on initiation or discontinuation or change of antibiotic therapy. Our aim was to determine the usefulness of PCT in our ICU. Methods PCT was measured once daily for all patients admitted to the ICU. Results were reviewed daily by intensivists and microbiologists and an appropriate decision about antibiotic therapy was made. We considered to stop antibiotics if the PCT was <0.5 ng/ml or had decreased to 80% of the peak value. CRP and clinical progression were also taken into consideration. Results One hundred and fourteen PCT values were obtained from 27 patients over 18 ICU days. PCT concentrations were lower than 0.5 ng/ml in 49 samples whilst CRP values were higher with a median of 107.5 mg/l. Antibiotics were discontinued or not initiated following low PCT values in 38 of these samples despite high CRP. For two patients who were already on antibiotics, a rise in PCT was noticed which prompted us to change the antibiotics. No new microbiologically proven systemic infection was identiied in any of the patients with low PCT values. See Figure 1. Conclusions Frequently, discrepancy between PCT and other inlammatory markers were noticed, suggesting an inlammatory response or nonbacterial infection and not necessarily an indication for antibiotics. Regular assessment of PCT, when interpreted with clinical context, was helpful not only to decrease the duration of antibiotics but also to change the antibiotic regimen. References 1. Shehabi Y, et al.: Crit Care 2008, 12:211. 2. Hochreiter M, et al.: Crit Care 2009, 13:R83. P43 Procalcitonin facing the postoperative culture results after liver transplantation J Fazakas1, E Papp1, G Ther1, Z Gallfy1, B Fule1, M Varga1, T Mandli1, S Toth1, J Fazakas2, L Kobori1, M Arkosy3 1 Semmelweis University, Budapest, Hungary; 2Bajcsy Zsilinszky Hospital, Budapest, Hungary; 3Soprponi Erzsébet Oktató Kórház, Sopron, Hungary Critical Care 2010, 14(Suppl 1):P43 (doi: 10.1186/cc8275) Introduction The early inlammatory response after liver transplantation (LTx) could be diagnosed by the simultaneous interpretation of procalcitonin (PCT) levels and culture results. The aim of this prospective, non-interventional study was to evaluate the prognostic signiicance of the PCT levels in the term of etiology (infection, colonization and noninfectious inlammatory states). Methods The PCT measurements and cultures were performed before surgery and on the irst ive postoperative days in 114 liver transplanted patients. The relationship between the absolute PCT levels (n = 762) and culture results (n = 474) was studied. The patients were divided into two groups according to the infection or colonization with Gram-positive (GP) or Gram-negative (GN) bacteria. Statistical analysis was done with the SPSS program. Results In 21 patients negative cultures were associated with PCT elevation (PCT: 3.77 ± 3.22 ng/ml), positive cultures were found in 107 patients, in 58 patients this was colonization (PCT <0.5 ng/ml). There signiicant diferences between the PCT elevation according to the etiology culture (GN, n = 36, PCT: 17.55 ± 11.3 ng/ml; GP, n = 222, PCT: 16.54 ± 6.58 ng/ml; P <0.02). Conclusions In the early phase after liver transplantation, the GP culture occurred more frequently; the GN culture could be associated with higher PCT elevation than those found in case of GP culture. P44 Can follow-up procalcitonin measurements shorten the periods of antibiotic administrations for septic patients? T Wada, A Hagiwara, R Sasaki, T Sato, K Kobayashi, A Inaka, T Sakamoto, Y Hagiwara, T Inagaki, K Katsuno, R Takegawa, A Kimura International Medical Center of Japan, Sinjyuku Tokyo, Japan Critical Care 2010, 14(Suppl 1):P44 (doi: 10.1186/cc8276) Introduction To examine whether we can safely shorten the periods of antibiotic administration for septic patients with procalcitonin (PCT) measurements compared with no PCT measurements. Methods The participants were septic patients including (1) hospitalized to our ICU from February 2009 to November 2009, (2) administered antibiotics for 4 days and over, and (3) stopped the antibiotics during their ICU stays. We treated the patients from February to June without PCT measurements (Group A). On the other hand, we treated the patients from July to November referring to serum PCT level (Group B). In group B, when Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S17 the serum PCT level decreases under 0.5 ng/ml, we stopped the antibiotic administrations if their systemic conditions were getting better. Results Twelve patients were in Group A, and 15 patients were in Group B. The ages were 65 ± 18 in Group A, and 64 ± 23 in Group B. The APACHE II scores were 20.4 ± 6.3 in Group A, and 18.5 ± 7.5 in Group B. There were no signiicant diferences. The periods of antibiotic administrations were 14.1 ± 7.7 days in Group A, and 9.7 ± 6.0 days in Group B. The periods in Group B tended to be signiicantly shorter than in Group A (P = 0.049). The C-reactive protein (CRP) levels were 3.5 ± 4.2 mg/dl in Group A, and 6.5 ± 4.1 in Group B when the antibiotic administrations were stopped. The CRP levels in Group B were higher than in Group A (P = 0.071). Two patients in Group B were repeated antibiotic administrations, while they were discharged without any complications. Conclusions The follow-up PCT measurements safely shorten the periods of antibiotic administrations for septic patients. We believe that PCT has good cost–beneit efects for critically ill patients. P45 Eiciency diagnostic and advantages of procalcitonin and C-reactive protein in the early diagnosis of sepsis M De la Torre-Prados, A García-de la Torre, A García-Alcántara, C Ortíz-García, A Enguix-Armada Hospital Virgen de la Victoria, Málaga, Spain Critical Care 2010, 14(Suppl 1):P45 (doi: 10.1186/cc8277) Introduction The goal of our study is to assess the diagnostic proitability of procalcitonin (PCT) in septic shock and another biomarker as C-reactive protein (CRP). Methods Case–control study. During 2009 we proceeded to select the sample: 54 patients (ICU) and 61 controls. PCT and CRP were set in the irst 24 hours besides the diagnosis and other analytical (glucose, lactate, leukocytes, platelets, white blood cells, LIC cells and ALY cells) and clinical parameters. There were realized diagnostic output curves (ROC), area under the curve (AUC), conidence interval (95%), cut-of and the comparison between AUC. Results Fifty-four septic patients were assessed, 66% were males; mean age, 63 years. Eighty-eight percent was diagnosed as septic shock and 11% severe sepsis. Seventy-six percent were medical patients. Positive blood cultures in 42.5%. Sepsis origin: respiratory 46%, neurological 5%, digestive 37% and urinary 3%. Average SOFA score was 10.4. Conclusions PCT and CRP have the same eiciency in early sepsis diagnosis. The PCT and CRP eiciency diagnostic together is signiicant but small. We suggest using both with the doubt of sepsis. P46 Biomarkers of sepsis in burn patients H Oueslati1, K Bousselmi1, I Rahmani1, A Mokline1, J Haddad1, Y Yahyia1, R Ghanem2, A Messadi1 1 Burn and Trauma Center, Tunis, Tunisia; 2Microbiology Department, Tunis, Tunisia Critical Care 2010, 14(Suppl 1):P46 (doi: 10.1186/cc8278) Introduction Sepsis is still the major cause of death in the late posttraumatic period in patients with major burns. Diagnosis of sepsis remains diicult in these patients where signs of sepsis may be present in the absence of real infection. This study attempted to assess whether the plasma procalcitonin (PCT) level was related to sepsis in burned patients. Methods PCT was measured over the entire course of stay in patients with predictive signs of sepsis according to Burn French Society Criteria (SFETB) for the presence of infection. The patients were assigned to two groups depending on the clinical course and outcome: A = no septic patients, B = septic patients. Optimum sensitivity, predictive values, and area under the receiver operating characteristic (ROC) curve were evaluated. Results Over a 6-month period starting from 1 July 2008 to 31 December 2008, 157 patients were admitted. Sixty-two were investigated, 40 in group A and 22 in group B. Procalcitonin was signiicantly higher in the septic group (7.26 ± 7 ng/ml) compared with the no septic group (0.25 ± 0.32 ng/ ml). Area under the curve was 0.94 on the day of sepsis diagnosis. A PCT cut-of value of 0.75 ng/ml was associated with the optimal combination of sensitivity (85%), speciicity (87%), positive predictive value (91%), and negative predictive value (73%). In surviving septic patients the PCT value was signiicantly lower than in deceased septic patients (3.5 ± 0.87 ng/ ml vs 10.18 ± 9.6 ng/ml). The PCT cut-of value for optimum prediction of outcome in septic patients was 3.66 ng/ml with sensitivity (91%), speciicity (75%), positive predictive value (78%), and negative predictive value (90%). Conclusions Procalcitonin appears to be a powerful marker of sepsis in burn patients. It is sensitive, speciic, reliable and easy to measure. A high PCT concentration (>3.66 ng/ml) would indicate poor outcome in septic patients. References 1. 2. Figure 1 (abstract P45). Comparison between AUC not signiicantly diferent for PCT and CRP (P = 0.445). Table 1 (abstract P45). Output curve results: PCT/CRP, sensitivity, speciicity Mean AUC PCT CRP 24 ng/ml 227 mg/day 0.983 0.965 0.93 to 0.99 0.91 to 0.99 Sensitivity 92.6% 91.1% Speciicity 93.1% 100% 95% CI Gramm HJ, et al.: A biological marker of the inlammatory response with prognostic properties. Clin Intens Care 1995, 6(Suppl):71. Zeni F, et al.: Procalcitonin serum concentrations and severity of sepsis. Clin Intens Care 1994, 5(Suppl):2. P47 Age-related diferences of outcomes in patients hospitalized with community-acquired pneumonia are not explained by diferences in immune response S Kale, S Yende, L Kong, A Perkins, JA Kellum, AN Vallejo, AB Newman, DC Angus University of Pittsburgh School of Medicine, Pittsburgh, PA, USA Critical Care 2010, 14(Suppl 1):P47 (doi: 10.1186/cc8279) Introduction We hypothesized that the higher risk of severe sepsis and mortality observed after infection in prior epidemiologic studies are due to age-related diferences in immune response. Methods We analyzed 2,183 subjects from a multicenter observational cohort of patients hospitalized with community-acquired pneumonia (CAP). We divided subjects into ive age groups (<50, 50 to 64, 65 to 74, 74 to 84, ≥85). To compare immune response, we measured circulating inlammatory (IL-6 and IL-10), coagulation-ibrinolysis (D-dimer, factor IX (F-IX), thrombin–antithrombin complex (TAT), antithrombin (AT) and plasminogen-activator inhibitor (PAI)), and cell surface markers (TLR2, Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S18 Figure 1 (abstract P48). Sensitivity analysis on CE (Base Case CE = $32,939/QALY). SIRS, sepsis, severe sepsis and septic shock or exit the model via discharge or death. Key literature assumptions are as follows: 91% efectiveness of empiric therapy, 70% BC efectiveness, 90% new test efectiveness, $750 cost/test, 9.5 years average life expectancy of sepsis survivor, 0.69 qualityadjusted life-year (QALY) for survivors, and turnaround times of 24 hours for the new test and 48 hours for standard BC. Results The model shows that the new test would be cost-efective when compared with current BC, at a cost of $32,939 per QALY (day 28). These results are compelling across a range of assumptions and almost all estimates fall below the US CE threshold of $50,000 to $100,000/QALY (Figure 1). Varying most assumed values by up to 25% had a moderate impact on CE. CE is sensitive to empiric test efectiveness >95%. More rapid diagnostic information lowered the cost/QALY. Conclusions Preliminary results show that a rapid and accurate test would be considered cost-efective across many assumptions and would reduce the mortality associated with delayed diagnosis. References 1. Figure 1 (abstract P47). Modest diferences in circulating concentration of coagulation-ibrinolysis markers on ED presentation (day 1) and over the irst 7 days. P1, day 1 P value from ANOVA model adjusted for sex, race, co-morbidity, and smoking status; Tobit models used for censored data. P2, day 1 to 7 P value from mixed efects model adjusted for sex, race, comorbidity, and smoking status; Tobmit models used for censored data. TLR4, HLADR) on emergency department (ED) presentation and during the irst week of hospitalization. Results Older subjects had higher rates of severe sepsis (14.8%, 23.0%, 26.3%, 34.0%, 42.3%) and 90-day mortality (1.8%, 3.8%, 9.2%, 18.2%, 19.8%, per age group (P <0.001)). However, there were no age-related diferences in inlammatory or cell surface markers and only modest diferences in coagulation-ibrinolysis abnormalities on ED presentation and over the irst week (P <0.05) (Figure 1). Conclusions Despite large diferences in outcomes, patients hospitalized with CAP displayed no age-related diferences in circulating inlammatory or cell surface markers and modest diferences in circulating coagulationibrinolysis markers. P48 Cost-efectiveness of a rapid and accurate test for diagnosing infection in severe sepsis and septic shock patients T Walke1, D Chalin2, J Lee1, E Rivers3 1 Altarum Institute, Ann Arbor, MI, USA; 2Abbott Diagnostics, Abbott Park, IL, USA; 3Henry Ford Hospital, Detroit, MI, USA Critical Care 2010, 14(Suppl 1):P48 (doi: 10.1186/cc8280) Introduction Prompt and accurate pathogen identiication is crucial for treatment of severe sepsis and septic shock (SS/SS). Blood cultures (BC) require 24 to 48 hours and often yield inaccurate results. Efective pathogen identiication allows for timely, targeted antimicrobial therapy. Methods A SS/SS Markov model [1] was developed to assess the costefectiveness (CE) of a rapid and accurate diagnostic test compared with the current standard. In the model, patients can transition between no SIRS, Rangel-Frausto et al.: Clin Infect Dis 1998, 27:185. P49 A multicentre study of bacteraemia using a new commercial universal 16S rDNA PCR test S Sakka1, N Wellinghausen2, A Kochem1, C Disque3, H Mühl3, S Gebert2, J Winter2, J Matten4 1 Medical Center Cologne-Merheim, Cologne, Germany; 2Universitätsklinikum Ulm, Germany; 3Hochschule Bremerhaven, Germany; 4MVZ Leverkusen, Cologne, Germany Critical Care 2010, 14(Suppl 1):P49 (doi: 10.1186/cc8281) Introduction Bloodstream infection is a life-threatening condition with a high mortality rate, especially in intensive care and neutropenic patients. Standard diagnostics is based on blood culturing (BC). However, limitations of BC include relatively low sensitivities and a long time-toresult for the identiication of the pathogen, generally over 2 days and more. On the grounds of data from a multicentre study using a universal 16S rRNA gene PCR assay, SepsiTest™, molecular diagnosis is discussed as a rapid and sensitive tool for the detection and identiication of pathogens supportive of BC. A new commercial PCR test, SepsiTest™, for direct detection of bacteria in whole blood was compared with BC in terms of sensitivity, speciicity, predictive values and time to positivity (TTP) of bacterial infections of the bloodstream of critically ill patients. Methods The test, SepsiTest™ (Molzym, Bremen), comprises the extraction and 16S rRNA gene PCR detection of bacterial DNA in whole blood samples. Bacteria in positive samples were identiied by sequence analysis of the amplicon. In a prospective multicentre study, 342 blood samples from 187 patients with systemic inlammatory response syndrome (SIRS), sepsis, or neutropenic fever were included. Results Compared with BC, the diagnostic sensitivity and speciicity of PCR/sequencing was 87.0% and 85.8%, respectively. The positivity rate of PCR/sequencing (25.7%) was higher than BC (15.8%). Of 31 PCR/ sequencing-positive, BC-negative patients, most of whom received antibiotics, the PCR results of 25 were judged as true or possible to bacteraemia. Using a routine testing worklow, time to positivity of the PCR test was on average decreased by 40 hours for anaerobe/fastidious infections and by 54 hours for yeast infections. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Conclusions The PCR approach enables the detection and identiication of bacteraemia in blood samples within a few hours. Despite the indispensability of BC diagnostics, the rapid detection of bacteria by SepsiTest™ appears to be a valuable tool, allowing earlier pathogenadapted antimicrobial therapy in critically ill patients. P50 Time to antibiotics in sepsis R Appelboam, R Tilley, J Blackburn Royal Devon and Exeter Hospital, Exeter, UK Critical Care 2010, 14(Suppl 1):P50 (doi: 10.1186/cc8282) S19 and admission APACHE II score of the study cohort was 61.8 (16.3) years and 18.4 (5.6). The median LOS and ICU mortality of the cohort was 24 days and 27.6%. The most common CDC reportable diagnosis was clinical or microbiological conirmed pneumonia (PNU1/PNU2/LRI) (n = 57), followed by intra-abdominal infection (SSI-GIT) (n = 10) and urinary tract infection (SUTI) (n = 8). The culture positivity rate was 71.2%. The appropriateness of the ICU antibiotic guideline is summarised in Table 1. Monotherapy was used in 52.5% of episodes. The median length of antibiotic treatment with positive cultures was 7 days, and 5 days for culture negative episodes. In sepsis episodes with negative culture, antibiotics were stopped within 3 days in 17% of the episodes. Table 1 (abstract P51). Appropriateness of guideline-based antibiotic therapy Introduction Mortality from sepsis increases with delay in administration of antibiotics. The Surviving Sepsis Guidelines suggest that antibiotics are administered within 1 hour of diagnosis of severe sepsis and septic shock. This retrospective study investigated the time to appropriate antibiotics in patients with sepsis and identiies reasons for delay where possible. Methods All adult patients in our institution who had positive blood cultures in 2008 were identiied. Included were patients with sepsis, severe sepsis, or septic shock. Excluded were the isolation of low-pathogenicity organisms from blood culture (for example, coagulase-negative Staphylococcus). Case notes were reviewed to identify the time between diagnosis of sepsis and administration of antibiotics. Time zero was taken as the time recorded in the notes by the doctor that the patient was seen. Times of prescription and administration of antibiotics were taken from the prescription chart. Results There were 1,477 sets of positive blood cultures in 1,098 patients. Following exclusions there were 503 episodes of positive blood cultures in 494 patients. Three hundred and seventy-ive fulilled the criteria and were analysed: 52 did not fulil entry criteria, in 16 cases sepsis was not suspected, and 60 sets of notes were incomplete or unavailable. Average age was 69 years. Mean time between diagnosis and antibiotic administration was 8.1 hours, median 4 hours. A delay of 3 hours or more between diagnosis and administration of antibiotics occurred in 218 cases (58%). The 28-day mortality for all patients overall was 21%; 19% in the no-delay group compared with 24% in the delayed group. The 1-year mortality was 35% for both groups. Causes of delay in administration included prescription error, awaiting senior review, and patient movement between departments. Conclusions These retrospective data demonstrate that there is a delay in administering antibiotics patients with sepsis. These data are likely to be an underestimation as an accurate time zero is diicult to ascertain. References 1. 2. 3. Kumar A, Roberts D, Wood KE, et al.: Crit Care Med 2006, 34:1589-1596 Dellinger RP, Levy MM, Carlet JM, et al.: Crit Care Med 2008, 36:296-327. Bone RC, Sibbald WJ, Sprung CL: Chest 1992, 101:1481-1483. P51 Utility of an antibiotic guideline in hospital-associated infections M Shankar-Hari, D Wyncoll Guy’s and St Thomas’ NHS Foundation Trust, London, UK Critical Care 2010, 14(Suppl 1):P51 (doi: 10.1186/cc8283) Introduction Prompt initiation of appropriate antibiotic therapy improves outcome in critically ill patients [1]. In a tertiary-level ICU, we evaluated the appropriateness of, and adherence to an antibiotic guideline (based on local bacterial epidemiology) in CDC-deined hospital-associated infections. Methods We conducted a 6-month prospective observational study (April 2008 to October 2008) in consecutive ICU admissions of patients who satisied investigator-adjudicated classiication of ICU-acquired infections according to CDC criteria [2]. We assessed patient characteristics including severity of illness at admission, ICU length of stay (LOS), appropriateness of initial antibiotic choice as judged by in vitro sensitivity results and appropriateness of the current guideline. Results are presented as mean (SD) or median as appropriate. Results During the study period there were 101 antibiotic starts in 65 patients with sepsis secondary to ICU-acquired infections. Medical patients formed 44% of the study cohort; whilst 23% of patients were general surgical and the remaining 33% were post cardiothoracic surgery. The age Parameter Septic shock (n = 35) Severe sepsis (n = 30) Sepsis (n = 36) Positive cultures 23 (66%) 25 (83%) 24 (67%) Appropriateness 18/23 (78%) 21/25 (84%) 14/24 (58%) Conclusions The study cohort had a high culture positivity rate (71%) in ICU-acquired sepsis. Our antibiotic guidelines gave an optimal empiric initial therapy in over 74% of episodes, with more than 50% of antibiotics started being monotherapy. References 1. 2. Kumar et al.: Crit Care Med 2006, 34:1589-1596. Horan et al.: Am J Infect Control 2008, 36:309-332. P52 Assessment of antibiotic prescriptions in two French intensive care units MP Parisot1, CT Tassin2, AL Lepape2, RG Gauzit1 1 Hotel Dieu, Paris, France; 2CHU Lyon Sud, Lyon, France Critical Care 2010, 14(Suppl 1):P52 (doi: 10.1186/cc8284) Introduction In the setting of antimicrobial policy, the French authorities recommend assessing the quality of antibiotic therapy [1]. The aim of this study is to assess the adequacy of antibiotic therapy in the ICU, to good practice guidelines and unit protocols. The three steps of prescription are analysed: choice of treatment, modalities of prescription and treatment follow-up. Methods This preliminary observational trial was conducted in two ICUs (October 2005 to August 2006 and March to August 2009). All patients with curative antibiotherapy were prospectively included. For each patient, we collected individual data of treatment and we evaluated them according to the recommendations of good use published in the literature [1,2]. Results One hundred and thirteen patients were included. Infections were community-acquired infection in 30% of the cases. Respiratory tract infections were the most frequently encountered, followed by intraabdominal infections. The three most frequently isolated pathogens were P. aeruginosa, E. coli and S. aureus. Initial antibiotic therapy, n = 113: lack of sample 14%, inadequacy with unit protocol 13%, too broad spectrum 7%, not justiied association 8%, wrong posology 20%, incorrect route of administration 1%, wrong interval 6%, lack of plasmatic dosage (n = 46) 7%. Treatment follow-up, n = 108: wrong delay of reappraisal 14%, no adaptation to microbiological results 10%, lack of de-escalation 5%, no reassessment of posology 3%, wrong posology (if change of treatment) 2%, wrong interval (if change of treatment) 3%, unjustiied duration 10%. Conclusions The rate of prescriptions that did not conform to at least one criterion in this study was over 70%. This high rate is partly explained by the high number of assessment criterions (n = 15). The most frequent criterion of inadequacy was a wrong initial dosage, followed by the initiation of an antibiotherapy without a microbiologic sample, a wrong delay of reassessment, and a nonconformity of treatment to unit protocols. That last criterion must be assessed in a more qualitative way, as some transgressions could be justiied. References 1. 2. Stratégie d’antibiothérapie et prévention des résistances bactériennes en établissement de santé [www.has-sante.fr] Van der Meer JW, et al.: Clin Microbiol Infect 2001, 7(Suppl 6):12. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P53 Occurrence of alert pathogens in the clinical materials and consumption of antibiotics in the ICU, in the years 2007 and 2008 K Wawrzyniak, A Mikucka, A Deptuła, E Gospodarek, K Kusza Nicolaus Copernicus University in Toruń, Collegium Medicum, Bydgoszcz, Poland Critical Care 2010, 14(Suppl 1):P53 (doi: 10.1186/cc8285) Introduction A continuous pressure of antibiotics and chemotherapeutics in ICU patients promotes isolation of multidrug-resistant (MDR) strains. Treatment of infections caused by microorganisms resistant to available drugs often results in a therapeutic failure. The purpose of this work was a retrospective comparison of the rates of isolation of particular MDR pathogen groups in 2007 vs 2008 in ICU patients hospitalised in a university hospital 11-bed reference department, and of antibiotic consumption in the analysed years. Methods Data concerning microbiological testing were analysed based on the WHONET software, version 5.4. The analysis rejected repeated identical culture results that did not relect a subsequent case of infection with a given MDR pathogen, but only persistence of the same strain in a given patient. Results MDR pathogen stains most frequently were isolated from the bronchoalveolar lavage (BAL) material. Carbapenem-resistant Gramnegative rods represented the highest rate (62% in 2007 and 64% in 2008); these included Pseudomonas aeruginosa strains (57% and 35%, respectively). Escherichia coli (11% in 2007), Klebsiella pneumoniae (12% in 2008) and Enterobacter cloacae (9% in 2008) predominated among ESBL-producing intestinal rods. A minor increase of the rate of the ESBL(+) strains was found in 2008. Single MRSA strains were isolated in the analysis period, no VRE were cultured. The highest antimicrobial drug consumption (DDD/100 person-days) in 2007 pertained to meropenem (20.6), piperacillin/tazobactam (20.0), cephazolin and vancomycin (11.6 and 11.1). The respective values for the year 2008 were as follows: piperacillin/tazobactam (20.8), voriconazole (19.7), meropenem (14.6). Conclusions A 47% increase in the MDR pathogen isolation rate was found in the year 2008. MDR nonfermenting rods represent the largest therapeutic and epidemiological challenge among the isolated MDR pathogens. In the subsequent analysed year, irst emergence of carbapenem-resistant Acinetobacter baumanii strains was noted. References 1. Rossolini GM, Mantengoli E: Antimicrobial resistance in Europe and its potential impact on empirical therapy. Clin Microbiol Infect 2008, 14:2-8. P54 Treatment cost of secondary peritonitis in Germany: a comparative study of medical cost incurred for tigecycline therapy and standard regimens J Kresimon1, U Theidel2, C Runge2, R Rychlik1, W Krueger3 1 Institute of Empirical Health Economic, Burscheid, Germany; 2Wyeth Pharma GmbH, Muenster, Germany; 3Clinics of Constance, Germany Critical Care 2010, 14(Suppl 1):P54 (doi: 10.1186/cc8286) Introduction Secondary peritonitis is the most frequent form of peritonitis, characterized by a high disease burden and a high mortality rate. Choice of adequate antibiotics is an independent factor for survival. The aim of this study was to compare treatment of secondary peritonitis with tigecycline (TG) with standard regimens (SR) from an economical standpoint. Methods After ethics committee approval, the study was performed as prospective, non-interventional cohort trial in 23 medical centers in Germany. Patients could be included if sufering from severe secondary peritonitis treated in an ICU. Patients with pregnancy, aged below 18 years and milder forms of diseases (APACHE II score <15) were not eligible. In order to compare treatment with TG with SR, the following data were documented: demographic data, disease severity scores, causing microorganisms, laboratory parameters, and length of stay (LOS). Patients were analysed according to initial antibiotic choice except for perioperative prophylaxis. In order to balance for diferences in co-morbidities and severity of disease, a matched-pairs analysis was performed based on logistic regression analysis. Results A total of 178 patients were enrolled (49 TG/129 SR). After logistic regression analysis and matching for gender, age ± 3 years, APACHE S20 II score ± 1 and (non)existence of liver cirrhosis, arterial sclerosis and coronary heart disease, 15 matched pairs were built. Compared with the SR group, in the TG group was a tendency for higher creatinine, urea and glucose levels, higher number of co-morbidities (3.3 vs 3.0, NS) and higher number of pathogens isolated on initial surgery (2.2 vs 1.6, NS). There was a higher number of discharges 9/15 in the TG group (vs 7/15 SR, NS) and 6/15 patients died (vs 4/15 SR, NS). Considering these factors, there was a trend for shorter LOS in patients treated with TG (11 days vs 18 days and 8 days vs 16 days for survivors and nonsurvivors, respectively, NS) and total costs of ICU stay were signiicantly lower in the TG group (€8,832 vs €15,482, P = 0.023). Conclusions In our non-interventional study, tigecycline tended to be used in patients with more severe co-morbidities. In spite of this, there was a trend for shorter LOS and treatment costs were signiicantly lower, which make tigecycline an attractive treatment, also from a pharmacoeconomical standpoint. P55 Colistin monotherapy versus therapy combination B Charra, A Benslama, H Ezzouine, S Motaouakkil CHU Ibn Rochd, Casablanca, Morocco Critical Care 2010, 14(Suppl 1):P55 (doi: 10.1186/cc8287) Introduction The purpose of our study was to compare the efectiveness of colistin monotherapy and colistin combination in the treatment of nosocomial infections with multi-resistant germs. Methods Retrospective study including 63 patients realized during 3 years from January 2006 to December 2008 in the medical ICU of University Hospital Ibn Rochd, Casablanca, Morocco. The study includes only the patients who sufer from nosocomial infection with multi-resistant germs, all of the sites are concerned. The patients have been divided into groups: group 1 including 30 patients treated by colistin only, and group 2 including 33 patients treated by the association colistin–rifampicin. The colistin has been administered intravenously and/or in nebulization and/ or in an intrathecal way according to the considered infectious site. The main criterion of judgment was the rate of mortality in the resuscitation unit, the second criteria of judgment were the ventilator weaning, the introduction of the vasoactive drugs and the supervening of side efects. Results Sixty-three patients judged as appropriate, have been included. The mean age of the patients was about 43.62 ± 17.34 years and APACHE 2 score at the admission was about 15 ± 5.69. The total mortality caused by infection was about 41.27%. The basic characteristics of the two groups were similar. The mortality in group 1 was about 36.66%, and about 69.69% in group 2 (P = 0.001), the rate of introduction of vasoactive drugs was about 23.33% in group 1 versus 48.48% in group 2 (P = 0.03). In group 1, 6,66% of the patients developed renal failure, against 12.12% of the patients in group 2 (P = 0,46). With the rifampicin, 27.27% of the patients of group 2 presented cytolysis. Conclusions This study suggests that colistin represents a good therapeutic alternative for the treatment of nosocomial infection with multi-resistant germs. However, our study is not without limits; it is a retrospective study, absence of randomization and the control group of patients. P56 Eicacy and safety of once daily dosing of colistin to critically ill patients A Skiada1, J Pavleas2, T Topalis2, K Georgiou2, D Siggouna2, G Thomopoulos2, GL Daikos1, G Floros2 1 University of Athens, Greece; 2Laiko General Hospital, Athens, Greece Critical Care 2010, 14(Suppl 1):P56 (doi: 10.1186/cc8288) Introduction Although colistin has been used extensively in critically ill patients infected with multidrug-resistant (MDR) organisms, our knowledge about the pharmacokinetic and pharmacodynamic parameters correlating with eicacy is very limited and little consensus exists on the optimum dosing regimen of this agent. In our center, during the past 2 years several patients treated with colistin were given the total daily dose once every 24 hours. The aim of this study was to analyze the eicacy and safety of this dosing regimen in critically ill patients. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Methods The medical iles of all patients who were admitted to the ICU in 2008 and who received colistin for an infection due to MDR bacteria were retrospectively analyzed. Criteria for inclusion were: dosing regimen of colistin 9 million units (MU) every 24 hours (colistin methanesulphonate – CMS, Norma, 1 vial = 1 MU, 1 mg = 13,300 U), administration of CMS for at least 7 days and normal renal function at initiation of treatment with CMS (serum creatinine ≤1 mg/dl or creatinine clearance >80 ml/min). Mortality was evaluated at 28 days. Results Thirteen patients were included in the study (69% male, median age 71 years). The underlying diseases were surgical in seven patients and medical in six patients. The median APACHE and SOFA scores on the irst day of CMS administration were 15 and 10, respectively. Eleven patients had nosocomial pneumonia, two had peritonitis and one osteomyelitis. Causative bacteria were isolated in 10 patients (six Acinetobacter baumanii, three Pseudomonas aeruginosa and one Klebsiella pneumonia) and were all MDR. Of the 10 isolated bacteria, six were susceptible only to colistin, while the other four were also susceptible either to aztreonam or sulbactam. In cases of susceptibility of the isolate only to colistin, it was given in combination with a carbapenem, while in the other cases either aztreonam or sulbactam was added. The median length of CMS administration was 11 days (mean 19; range 7 to 79 days). Median serum creatinine on initiation and completion of treatment with CMS was 0.7 and 0.9 mg/dl, respectively (P = 0.357). No cases of neurotoxicity were found. Mortality at 28 days was 15%. Conclusions The total daily dose of 9 MU of CMS, given as one dose every 24 hours in critically ill patients, seems to be eicient and safe, without resulting in increased nephrotoxicity or other adverse events. A prospective study should be done to conirm the indings we have presented herein. P57 A comparison of the efect on renal function of lucloxacillin and vancomycin antibiotic prophylaxis in cardiac surgery patients TO Brougham, K Giraud, A Vuylsteke Critical Care Unit, Cambridge, UK Critical Care 2010, 14(Suppl 1):P57 (doi: 10.1186/cc8289) Introduction This study compared the efect on renal function of lucloxacillin and vancomycin antibiotic prophylaxis for elective irsttime coronary artery bypass grafting (CABG) surgery, using both direct biochemical markers and indirect clinical outcome measures. Recent evidence has suggested that vancomycin may be nephrotoxic in patients undergoing cardiac surgery. Methods A retrospective observational study of patients undergoing elective irst-time CABG was performed, covering a 13-month period. All patients received prophylactic antibiotics: lucloxacillin 1 g pre-operatively and three 1 g doses post-operatively. Patients who were MRSA-positive, MRSA unknown or penicillin allergic received an alternative regimen: vancomycin 1 g pre-operatively and 1 g post-operatively. Exclusion criteria: preoperative creatinine >133mmol/l, any antibiotics other than prophylaxis and haemodynamic support except <5 μg/kg/hour dopamine. Results Of 1,413 patients in the study period, 415 met the study criteria: 360 patients received lucloxacillin and 55 patients received vancomycin. There were no signiicant diferences between the two groups in sex, age, BMI, euroSCORE, diabetes status, ejection fraction, pre-operative creatinine, eGFR, sodium, or potassium. Comparing change in renal function pre-operatively to post-operatively, there were no signiicant group diferences in change in: creatinine (mmol/l; VAN median 0 (IQR 11); FLU –2 (19); P = 0.22), eGFR (ml/min; VAN 0 (14); FLU 2.4 (19.3); P = 0.22), sodium (mmol/l; VAN 1 (4); FLU 1 (4); P = 0.28). Change in potassium difered signiicantly (mmol/l; VAN 0.7 (0.9); FLU 0.5 (0.7); P <0.05). In clinical outcome measures, the groups were similar. Most patients in both groups stayed in ITU for 1 day and there was no signiicant diference in the number of patients staying for longer than 1 day (VAN 7/55 (13%); FLU 29/360 (8%); P = 0.30). There was no diference in hospital length of stay (days; VAN 7 (4); FLU 6 (3); P = 0.19). Conclusions In elective irst-time CABG patients, there is no signiicant diference in change in renal function between those given vancomycin antibiotic prophylaxis and those given lucloxacillin prophylaxis, as assessed by creatinine, eGFR and sodium levels, and indirect clinical outcome measures. Potassium increased more in the vancomycin S21 group but the clinical signiicance of this is unclear. Our data suggest that prophylactic vancomycin does not impair renal function relative to lucloxacillin. P58 Microdialysis study of meropenem cerebral distribution in patients with acute brain injury C Dahyot-Fizelier1, I Timofeev2, S Marchand1, W Couet1, P Hutchinson2, B Debaene1, D Menon2, O Mimoz1, A Gupta2 1 University Hospital, Poitiers, France; 2Addenbrooke’s Hospital, Cambridge, UK Critical Care 2010, 14(Suppl 1):P58 (doi: 10.1186/cc8290) Introduction Antibiotic dosing recommendations are usually based on plasma or cerebral spinal luid pharmacokinetic (PK) studies. However, as infections mainly occur in extracellular tissue luid (ECF), corresponding unbound ECF antibiotic concentrations are responsible for the antimicrobial efect. Because of the blood–brain barrier, the cerebral antibiotic distribution is thought to be reduced compared with tissues without any physiological barrier. This study aims to determine meropenem (MPM) unbound concentrations in the brain and compare them with MPM concentrations in plasma to explore cerebral distribution of MPM in patients with acute brain injury. Methods After local ethic approval and written informed consent, two brain-injured patients, sedated, mechanically ventilated, receiving MPM for an infection and monitored by cerebral microdialysis (CMA 71, membrane length 10 mm, membrane diameter 0.6 mm, molecular cut-of 100 kDa; CMA, Stockholm, Sweden) were enrolled. The PK study succeeded to 1 g meropenem over 30 minutes and brain dialysates and blood samples were collected over 420 minutes. Probe recoveries were evaluated individually by retrodialysis. MPM was assayed by HPLC coupled with tandem mass spectrometry (LC-MS/MS). Results For each of the two patients, the MPM brain AUC is much lower than plasma AUC and accordingly brain to serum AUC ratios are respectively 0.73 for Patient 1 (P1) and 0.14 for Patient 2 (P2). MPM concentration versus time curves in brain are delayed (time-to-peak in P1 = 100 minutes, in P2 = 80 minutes) and present a smooth peak compared with the corresponding curves in plasma (Figure 1). Mean probe recoveries are respectively 19 ± 7% for P1 and 29 ± 7% for P2. Conclusions The MPM brain AUC is much lower than plasma AUC for the two patients enrolled, consistent with the PK theory in the presence of tissue with elux transporters. More patients are needed to better understand MPM brain distribution characteristics. Figure 1 (abstract P58). Individual MPM plasma (䊊) and brain (䊉) concentrations versus time in P1 and P2. P59 Efects of two regimens of antibiotic prophylaxis on colonizing lora of the respiratory tract in patients with cardiovascular surgery EM Berg, R Wesselink, M Tersmette Sint Antonius Hospital, Nieuwegein, the Netherlands Critical Care 2010, 14(Suppl 1):P59 (doi: 10.1186/cc8291) Introduction Antibiotic prophylaxis in cardiovascular (CV) surgery has greatly reduced the rate of postoperative infections. First-generation or second-generation cefalosporines are used for this purpose. Our hospital changed its antibiotic prophylaxis protocol for elective CV surgery in June 2007 from cefuroxime to cefazolin in accordance with national guidelines Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 [1]. The aim of this study was to explore the efect of changing this antibiotic prophylaxis protocol on microbial lora in sputum. Methods Retrospective study. All patients admitted >10 days on the ICU after elective CV surgery between 1 June 2006 and 1 June 2007 (Group 1) were compared with the same group of patients between 1 July 2007 and 1 August 2008 (Group 2). Patients received single-dose prophylaxis (bypass surgery), or 2 days of prophylaxis (cardiac prosthetic surgery). Group 1 received cefuroxime and Group 2 received cefazolin. Patients did not receive selective digestive tract decontamination. Isolated pathogens from elective sputum cultures of all patients were registered and compared between groups after dividing pathogens into six classes based on the proile of intrinsic antibiotic susceptibility. Comparative data between groups were analyzed with Pearson’s Χ test. Results One hundred and ifty-eight patients had positive sputum cultures. Comparing total amounts of positive cultures, there was no signiicant diference between colonization with pathogenic micro-organisms between Group 1 (n = 77 patients) and Group 2 (n = 76 patients). In Group 1 more colonization with pathogens from class 4 (β-lactamase-producing Enterobacteriaceae and Pseudomonas aeruginosa) was observed compared with Group 2 (45% vs 34%, P = 0.079). This nonsigniicant diference between groups was mainly attributable to a diference in colonization with Pseudomonas. In the other classes of pathogens, no diferences were observed. No diference in postoperative wound infections was noted between groups. Conclusions Prophylactic use of cefazolin instead of cefuroxime after CV surgery resulted in a trend towards reduction of colonization of the respiratory tract with intrinsic β-lactam-resistant microbial lora in patients with prolonged ICU stay, without adverse efects on the incidence of postoperative wound infection. Reference 1. van Kasteren MEE, et al.: Ned Tijdschr Geneeskd 2000, 144:2049-2055. P60 Prevalence of infections among patients admitted to ICUs in Nordic countries and the Netherlands in comparison with Mediterranean countries: a report from the EPIC II study H Hanberger1, H Gill1, H Njimi2, S Walther1, JL Vincent2 1 Antibiotic Research Unit, Linkoping, Sweden; 2Erasme Hospital, Brussels, Belgium Critical Care 2010, 14(Suppl 1):P60 (doi: 10.1186/cc8292) Introduction The prevalence of infection is high among patients admitted to the ICU and one of the main causes of mortality. The aim of this study was to determine the burden of infectious diseases in patients admitted to ICUs in Nordic countries and the Netherlands in comparison with Mediterranean countries. Methods The EPIC II 1-day point prevalence study of infections and demographics of critically ill patients was performed on 8 May 2007. A comparison of severity score, source of infection, co-morbidity and patient outcome was done for patients admitted to ICUs in low antibiotic resistance countries (LARC) (Denmark, Finland, the Netherlands, Norway, Sweden) and high antibiotic resistance countries (HARC) (Greece, Israel, Italy, Malta, Portugal, Spain, Turkey). Results The number of patients included was 2,270 in HARC and 581 in LARC. On the day of the study, 45.3% of patients in LARC were considered as infected compared with 51.6% in HARC (P = 0.007). The mean SAPS II scores were (95% CI) 32.7 (31.6 to 33.8) in LARC and 35.6 (35 to 36.2) in HARC (P <0.001). Of all patients in LARC/HARC, 27.0%/33.9% (P = 0.002) had a respiratory infection, 10.8%/9.8% (P = 0.45) an abdominal infection, 7.2%/10.4% (P = 0.023) a blood infection, 2.8%/3.2% (P = 0.60) a skin infection, 2.1%/3.4% (P = 0.09) a catheter infection, 3.8%/6.6% (P = 0.012) a genitourinary infection and 0.7%/1.7% (P = 0.08) a CNS infection. Chronic renal failure was seen in 2.6% of patients in LARC and 7.3% in HARC (P <0.001) and the corresponding prevalence of chronic obstructive disease was 13.4% and 20.2%, respectively (P <0.001). Admissions were more often seen from OR/monitoring and less often from emergency rooms among patients admitted to ICUs in LARC compared with HARC. Median ICU length of stay (LOS) in LARC (IQR) was 5 days (1 to 19) and in HARC was 12 days (3 to 31) (P <0.001). The corresponding hospital LOS was 16 days (7 to 38) and 24 days (10 to 54), respectively (P <0.001). The ICU mortality rates in LARC/HARC were 14.9%/19.9% (P = 0.008) for S22 all patients and for infected patients 21.2%/25.4% (P = 0.17), whereas the corresponding hospital mortality rates were 20.8%/26.7% (P = 0.005) for all patients and for infected patients 29.6%/34.3% (P = 0.16). The prevalence of MRSA was 0.8% among patients in LARC (5.8% in HARC) (P <0.001) and the prevalence of P. aeruginosa was 9.9% and 14.0% (P = 0.07), respectively. Conclusions Infections and serious co-morbidities were more prevalent among patients admitted to ICUs in HARC than in LARC. This was associated with a longer stay and greater mortality in the ICU. References 1. Vincent JL, et al.: JAMA 1995, 274:639-644. P61 Risk factors for the development of carbapenem-resistant Klebsiella pneumoniae infections in critically ill patients KZ Vardakas, DK Matthaiou, E Antypa, A Grammatikos, E Chasou, E Antoniadou G. Gennimatas, Thessaloniki, Greece Critical Care 2010, 14(Suppl 1):P61 (doi: 10.1186/cc8293) Introduction We sought to study the characteristics and outcomes of ICU patients with carbapenem-resistant (CRKp) and carbapenem-sensitive (CSKp) K. pneumoniae infections. Methods A retrospective cohort of patients requiring ICU treatment. The study was conducted in an eight-bed ICU between January 2006 and September 2009. Results During the study period, 104 patients were diagnosed with K. pneumoniae infection. The mean age of patients was 66.3 ± 14.3 years. Fifty-one (49%) were males. The mean APACHE II score was 17.9 ± 6.9. The median duration of hospital stay until the infection was 28 days. Fortyeight patients (46.2%) had bacteremia, 27 (30%) urinary tract infections, 15 (14.4%) pneumonia, seven (6.7%) peritonitis and seven (6.7%) skin and soft tissue infections. Fifty-eight (56.9%) and 39 (39%) patients had previous and concurrent infections, respectively. Seventy-six patients (73.1%) died. The univariate analysis showed that prior hospitalization (P = 0.049), dialysis (P = 0.034), and history of urologic neoplasia (P = 0.041) were associated with the development of carbapenem-resistant infections. No independent risk factors were found in the multivariate analysis. APACHE II score (P = 0.003), need for dialysis (P = 0.034), shock prior and after the infection (P = 0.006 and P <0.001, respectively), respiratory distress prior and after the infection (P = 0.021 and P = 0.032, respectively), multiorgan failure prior and after the infection (P = 0.02 and P = 0.003, respectively), treatment failure (P <0.001), and acidosis after the development of infection (P = 0.003) were associated with death in the univariate analysis. Shock after the infection (P = 0.016) and treatment failure (P = 0.001) were independent predictors of mortality in the multivariate analysis. No diference in mortality was found between patients with CRKp and CSKp isolates. Conclusions Infection due to K. pneumoniae in the ICU is associated with high mortality. Infection treatment and hemodynamic support of the patient may be important determinants of the clinical course in critically ill patients with such infections. Reference 1. Falagas ME, et al.: Risk factors of carbapenem-resistant Klebsiella pneumoniae infections: a matched case control study. J Antimicrob Chemother 2007, 6:1124-1130. P62 Outcome of unimicrobial versus polymicrobial sepsis N Abed1, A Hussein1, S Salaheldine1, A Hassan2, M Mahfouz1, H Khaled Nagi1, H Khaled Nagi1 1 Cairo University, Cairo, Egypt; 2National Heart Institute, Cairo, Egypt Critical Care 2010, 14(Suppl 1):P62 (doi: 10.1186/cc8294) Introduction Polymicrobial sepsis is associated with immunosuppression caused by the predominance of anti-inlammatory mediators and profound loss of lymphocytes through apoptosis, and so deaths directly related to sepsis are twofold higher in polymycrobial sepsis. The aim of study is to compare unimicrobial versus polymicrobial sepsis as regards microbiology, complications, length of stay, mortality, factor afecting mortality. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Methods One hundred and one patients with sepsis were studied and divided into two groups. The irst group: unimicrobial, where one organism was isolated from cultures; and the second group: polymicrobial, where more than one organism was isolated from the cultures. Results The irst group (unimicrobial) was 48 cases (47.5%) and the second group (polymicrobial) was 53 cases (52.47%). Both groups has similar positive sputum cultures (32/48 (66%) versus 38/53 (71%), P value 0.6), but positive blood culture was signiicantly higher in the second group (27/53 (51%) vs 7/48 (14%), P value 0.0001). There was also a signiicantly higher incidence of UTI and wound infection in the second group (49.7% vs 6.3% for UTI, P value 0.0001 and 20.7% vs 2.1%, P value 0.004 for wound infection, respectively). The commonest detected organisms were Staphylococci and Klebsiella (48, 22 out of 101 patients); 16/48 (33%) in unimicrobial vs 32/53 (60%) in polymicrobial (P value 0.007) for staph, and 7/48 (14.5%) in unimicrobial vs 15/53 (28%) in polymicrobial for Klebsiella (P value 0.09). Incidence of Acinetobacter, Candida and E. coli in the second group were signiicantly higher 10/53 in poly vs 2/48 in unimicrobial (P value 0.032), and 10/53 vs 0/48 (P value 0.002 ) and 6/53 vs 0/48 (P value 0.016), respectively. Need for mechanical ventilation in the second group was signiicantly higher than the irst group (46/53 (86%) vs 31/48 (64%), P value 0.009). The mean hospital stay was longer in the second group (26.9 ± 15.4 vs 17.4 ± 9.3, P value 0.001). Mortality was signiicantly higher in the second group (P value 0.012). Factors increasing mortality in both groups were DCL (P value 0.007 in unimicrobial and 0.036 in polymicrobial); vasopressors (P value 0.001 and 0.002, respectively); mechanical ventilation (P value 0.00 and 0.00, respectively), and severe sepsis and septic shock with signiicant P value (0.019) and (0.008), respectively, for the irst group and (0.003) and (0.002), respectively, for the second group. Conclusions Polymicrobial sepsis shows higher risk for complication, length of stay and mortality than unimicrobial. Reference 1. Aliaga et al.: Eur J Clin Microbiol Infect Dis 2000, 19:871-874. P63 De-escalation practice pattern in an Indian intensive care unit A Bhakta, M Bhattacharyya, S Todi AMRI Hospitals, Kolkata, India Critical Care 2010, 14(Suppl 1):P63 (doi: 10.1186/cc8295) Introduction Antibiotic de-escalation is thought to be beneicial by reducing the selection pressure for resistance. This study was carried out to identify variables that inluence de-escalation practices. Methods Prospective observational study during a 1-year period (July 2008 to June 2009) in a 50-bed ICU in a tertiary care hospital. Any patient admitted to the ICU during this period in whom at least one specimen was sent for microbiological culture at or before starting antibiotics was included in the study and subsequently followed up for antibiotic change according to the culture sensitivity report. Antibiotics covering Gramnegative organisms were ranked as per Figure 1. S23 Results Seven hundred and seventy-eight patients were included, of whom cultures were positive in 551 (70.8%) and negative in 227 (29.2%) cases. In 350 (44.9%) patients, neither escalation nor de-escalation of therapy was done. Overall escalation of therapy occurred in 192 (24.7%) patients and de-escalation in 236 (30.3%). The mortality rate was lowest among patients in whom therapy was de-escalated (8.9%) compared with categories of no change (14.2%) or escalation (23.4%). De-escalation occurred more frequently among patients in whom no pathogen was isolated (45.8%) compared with culture-positive cases (23.9%) and in 18.3% of patients with growth of drug-resistant pathogens, compared with 38.9% of patients with susceptible pathogens. De-escalation occurred most frequently where an antibiotic having only Gram-positive coverage was included in the initial empiric therapy (60.3%), and in cases where third-generation cephalosporin was the initial empiric therapy (54.4%). Conclusions This study highlights no change of therapy as the most prevalent practice pattern of antibiotic use. Mortality remained low in patients in whom therapy was de-escalated. Variables favoring deescalation practices were non-isolation of pathogen, growth of susceptible organisms, and stopping of Gram-positive coverage. P64 Incidence, identiication of multidrug-resistant pathogens and impact on the outcome after cardiac surgery A Tasouli, K Papadopoulos, G Stravopodis, C Panagiotou, J Kriaras, S Geroulanos, G Saroglou Onassis Cardiac Surgery Center, Athens, Greece Critical Care 2010, 14(Suppl 1):P64 (doi: 10.1186/cc8296) Introduction Multidrug-resistant (MDR) pathogens constitute an emerging threat with increasing incidence and uncertain outcome. On the other hand, patients undergoing open heart surgery represent a vulnerable population. Methods Evaluation of the incidence and identiication of MDR pathogens after cardiac surgery in 2,803 patients for a 2-year period. Examination of the clinical features of patients with MDR infection. Elucidation of the impact on the outcome. Results In 18 patients (0.64%) consisting of 12 males and six females, at least one MDR pathogen was isolated. Gram-positive pathogen was certiied in ive patients (27.8%) and Gram-negative in 13 patients (72.2%). Speciically, four patients were infected with vancomycin-resistant enterococcus (VRE), six with Klebsiella pneumoniae, three with Acinetobacter spp., one with VRE and Acinetobacter spp., four with Acinetobacter and K. pneumoniae. Low output syndrome (CI <2.0l/min/m2) was common in all these patients and essentially contributed to the deterioration of clinical situation with dependence on inotropic support, prolonged mechanical ventilation (>10 days), acute renal failure and need for haemodilution (66.6%). Therefore, the ICU and hospital stay is prolonged (>20 days and >30 days, accordingly) and pathogenesis of MDR infection is provoked after 20 days of ICU stay. Consequently, nine patients with MDR infection (50%) died. All were critically ill patients with multiple organ dysfunction syndrome under broad-spectrum antimicrobials with hospital-acquired bloodstream MDR bacteremia. Conclusions Infection with MDR pathogens, while rare, constitutes a notable prognostic marker of increased mortality after cardiac surgery. It is worth noting that the higher mortality rate is mainly attributable to the severe co-morbidity in haemodynamically compromised patients. Management must concentrate on the implementation of efective preventative strategies. P65 Surveillance of ICU-acquired infections in Belgium: 2008 reference data I Morales, B Catry, K Mertens Scientiic Institut of Public Health, Brussels, Belgium Critical Care 2010, 14(Suppl 1):P65 (doi: 10.1186/cc8297) Figure 1 (abstract P63). Antimicrobial therapy ranking. Introduction This paper aims to provide reference data for pneumonia (PN) and bloodstream infections (BSI) acquired in Belgian ICUs taking patients’ characteristics into account. This information could enlighten policy decisions. This 2008 set of indicators is the irst yielded by the ICU Belgian surveillance (NSIH-ICU) since 2001. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Methods The NSIH-ICU is a voluntary, patient-based reporting system set up in 1992 to follow ICU-acquired infections and guide prevention. It establishes a national risk-adjusted benchmark for infection rates, antibiotics use and invasive device-use ratios through uniform case deinitions, data-collection methods, data entry and analysis. Only patients staying more than 2 days in the ICU are included. These aggregated database means are derived from the NSIH-ICU 2008 report. Results In 2008, 4,355 patients and 35,802 patient-days were reported by 19 ICUs. The age mean was 67.2 years; mean length of stay 8.1 days; mean SAPS II score 43.8; the proportion of patients with antibiotics at admission was 47.1%; medical admissions represented 63.4%, 4.2% were immunocompromised patients; trauma was reported in 6.7% of cases. Overall ICU mortality was 8.5%. The proportion of intubated patients was 44.4%, with central venous catheters (CVC) 68.3% and with urinary catheters 58.3%. Invasive-device use rates were: 358.5 intubation-days, 746.5 CVC-days and 644.2 urinary catheter-days per 1,000 patient-days. The ICU-acquired PN/100 patients was 9.8, 16.5/1,000 patient-days and the intubation-associated PN was 11.1/1,000 intubation days. ICU-acquired BSI was 3.6/100 patients, 5.3/1,000 patient-days and the catheter-related BSI was 4.3/1,000 catheter-days. Conclusions The 2008 report provided Belgian hospitals with comparative ICU-acquired infection data adjusted for patients’ intrinsic and extrinsic infection risks. The participation changed across time and could cause a selection bias. Outlier veriication is ongoing and eforts to increase the participation are being made. Indicator rates could be related to protocol modiication, demographic trends and changes in patient mix linked to restructuration of medical services or in clinical practice patterns. Some are vulnerable to continuous medical and nursing in-service training, for example at surveying the antibiotics use and improving invasive devices use. Further studies could assess to what extent modiications in clinical practice and/or external interventions might cause changes in the patient mix. P66 Risk of acquiring drug-resistant (MDR) Gram-negative isolates with previous exposure to antibiotic A Bhakta, M Bhattacharyya, S Todi AMRI Hospitals, Kolkata, India Critical Care 2010, 14(Suppl 1):P66 (doi: 10.1186/cc8298) Introduction Prior antimicrobial therapy is one of the most important factors leading to the acquisition of MDR organisms. Formulating antibiotic policy and choice of empirical antibiotic selection will be helped by knowing the association of MDR Gram-negative organisms with a previous exposure of particular antibiotic. Methods Prospective observational study during January 2008 to June 2009 in a 50-bed ICU in a tertiary care hospital. Specimens sent after 2 days of the start of the antibiotic and no more than 90 days from the stop date have been included in the study. Analyses were based on those specimens that resulted in detection of MDR Gram-negative organism. Observed relative risk (RR) of an antibiotic class was computed with respect to an MDR infection. RR was computed as the ratio of the risk of the event (acquiring the infection) occurring in the exposed group vs in the nonexposed group. A logistic regression model was used where multiple antibiotics were applied. Results A total of 1,072 specimens from 500 patients met the criteria as speciied above. Of these, 423 (39.4%) specimens resulted in detection of MDR bacteria, 186 (17.4%) resulted in detection of non-MDR bacteria and no bacteria were detected in the remaining 463 (43.2%) specimens. Of the total 423 cases of MDR acquisitions, ESBL Enterobacteriaceae (151 or 35%), MDR Acineto (89 or 21%) and MDR Pseudo (58 or 14%). Risk of isolating ESBL Enterobacteriaceae was highly signiicant with the prior exposure to third-generation cephalosporin (RR = 5.8 and P <0.001). Risk of isolating MDR Acinetobacter spp. was highly signiicant with the exposure to piperacillin-tazobactam (RR = 2.7 and P <0.001). Risk of isolating MDR Pseudomonas spp. was signiicant with the exposure to Group 2 carbapenem (RR = 2.2 and P >0.001). Group 1 carbapenem, aminoglycosides have not been found to have signiicant association with any individual MDR organisms. Conclusions Previous exposure to antibiotics leads to increased acquisition of MDR organisms. There is a signiicant association of isolating S24 Figure 1 (abstract P66). Observed relative risk of MDR infections for diferent antibiotic classes. diferent MDR organisms with previous exposure to a particular class of antibiotic. P67 Ozone fumigation successfully controlled and eradicated multidrug-resistant Acinetobacter baumanii from an intensive care unit R Stümple, A Castello-Cortes, F Coogan, PB Nielsen Northwick Park Hospital, London, UK Critical Care 2010, 14(Suppl 1):P67 (doi: 10.1186/cc8299) Introduction The emergence of multidrug-resistant Acinetobacter baumanii (MDRAB) poses a serious threat to patients on the ICU. The production of metallo-β-lactamase leaves colistin as the only therapeutic option. Outbreaks due to MDRAB can persist for months. Traditional decontamination methods fail to deal with this level of colonisation and contamination efectively. We tackled a recent outbreak of MDRAB efectively using gaseous ozone. To our knowledge it is the irst time ozone has been used to control an outbreak of MDRAB. Methods An external company (Hydrozone Environmental Ltd) was hired to perform the fumigation. The ICU was divided into three decontamination areas using heavy-duty polythene sheets. Patients were in turn relocated from contaminated to clean areas before each area was sealed and fumigated. Humidity levels within were raised to 70 to 80% using a humidiier. An Ozone Ultra Pro 16 g/hour ozone generator with ozone destruct capability, operated remotely, delivered ozone to a target concentration of >2.0 ppm for 15 minutes. A fan was used to achieve even dispersal. For safety reasons perimeter ozone concentrations were monitored with a UV photometer and kept below 0.05 ppm. The eicacy of the fumigation was measured by environmental microbiological sampling before and after fumigation. Results All fumigated areas received ozone concentrations of 4.62 to 5.66 ppm for 21 to 32 minutes. Ozone was not detected outside the treatment areas. Prior to fumigation, 72 (38%) of 188 environmental samples were MDRAB-positive. Following fumigation, nine (5%) of 158 samples were positive. Most of these samples were from nontouch areas, for example ceiling, above door frame with signiicant dust collection and without daily cleaning. Considering that dust may impede ozone penetration, Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 basic cleaning was improved and duration of fumigation was increased to 30 minutes. Subsequent samples all proved negative and no further cross-infections occurred. Conclusions This is the irst study using ozone fumigation as a disinfectant to control an outbreak in an ICU. Ozone fumigation is an efective tool for eradicating MDRAB from heavily contaminated clinical sites. Used in conjunction with good infection control measures, ozone can be used to control outbreaks such as MRSA, Clostridium diicile, Norovirus and swine lu. P68 Viral infections in the ICU: should we search for them? M Sousa, M Monteiro, V Alves, C Granja Hospital Pedro Hispano, Matosinhos, Portugal Critical Care 2010, 14(Suppl 1):P68 (doi: 10.1186/cc8300) Introduction Respiratory viral infections are usually self-limited in adults but 4 to 30% can be clinically severe and lead to intensive care needs. The aim of this study was to determine the impact of viral respiratory infections in an intensive care setting and the role of systematic viral testing in patients admitted to an ICU. Methods A retrospective analysis of all 114 viral tests of respiratory samples of 98 patients admitted to the ICU for four consecutive years was performed. Molecular biology test and immunoluorescence assay for adenovirus, inluenza A and B, parainluenza 1 to 3, metapneumovirus and syncytial respiratory virus (SRV) were performed in tracheal aspirate (TA) (89%) and bronchoalveolar lavage (BAL) (11%). SAPS II was used as the severity index. Patients were stratiied according to the primary diagnostic. Results Viral tests were performed in 98 patients, 60% were male, mean age 58 years old and 45% had previous respiratory disease. SAPS II was 48. Ninety-two percent need mechanical ventilation (MV) for 8.5 days. Primary diagnostics were community-acquired pneumonia (CAP) (50%) or tracheobronchitis (32%), chronic pulmonary disease exacerbations (6%), aspiration pneumonia (3%), nosocomial infection (5%), septic shock (3%) and meningitis (1%). Length of stay (LOS) was 11 days and ICU mortality was 17.5%. Virus identiication was positive in 13 (12.2%) respiratory samples of 12 patients, 12 in TA and one in BAL. Twelve were identiied in the winter. Demographic variables, LOS, co-morbidities and severity index of patients with viral infection were similar to the main group. Inluenza A (in three CAP, one tracheobronchitis, one nosocomial infection and one septic shock), metapneumovirus (two tracheobronchitis and one CAP), inluenza B (one CAP), parainluenza 3 (one CAP) and SRV (one tracheobronchitis) were identiied. In these patients, C-reactive protein was higher and leucocytes were lower. Bacterial co-infection was identiied in 33% of the patients, all of them with acquired community pneumonia. Antibiotic step down was done in 62% of the patients with isolated viral infection. In these patients LOS and days of mechanical ventilation were 9.6 and 6.2, respectively, and invasive ventilation-associated pneumonia was reduced. Conclusions Although viral tests should not be required for all ICU patients, respiratory samples for viral tests should be performed in patients with tracheobronchitis/pneumonia requiring intensive care, especially in the winter. Positive identiication of viral agents could be useful in antibiotic policy. P69 Oseltamivir dosing with haemoiltration M Tomlin1, B Skinner1, J Fennell1, EP Pelosi1, SK Khoo2, NL Lindegardh3 1 Southampton University Hospitals NHS Trust, Southampton, UK; 2University of Liverpool, UK; 3Mahidol University, Bangkok, Thailand Critical Care 2010, 14(Suppl 1):P69 (doi: 10.1186/cc8301) Introduction In the current pandemic it is likely that some patients will be admitted to hospital and require respiratory support including mechanical ventilation. These patients are likely to have a profound systemic inlammatory response syndrome (SIRS); consequently they may have multiorgan failure (MOF) requiring renal replacement therapy (RRT) with haemoiltration. Two questions then arise – what dose of oseltamivir (Tamilu) should we give these patients to shorten the duration of the H1N1 infection? How should we modify the dose in response to altered renal drug clearance and in those requiring RRT? S25 Methods A young adult female patient with H1N1 infection and MOF was given oseltamivir 75 mg BD nasogastrically. Failure to respond changed the risk: beneit ratio and justiied doubling the dose despite uncertainties over an overall reduced clearance. Enteral nutrition absorption was uncertain, and thus we sampled her blood to ensure adequate oseltamivir absorption and that activation of the pro-drug was not inhibited. We undertook serial sampling for blood concentration assay to determine the pharmacokinetic parameters in this diicult scenario. Blood samples were collected in plain serum tubes (without sodium luoride). The samples were spun and refrigerated within half an hour, then batched and shipped to Bangkok for drug concentration measurement. Results We report both the parent oseltamivir phosphate (OP) and that of the active metabolite oseltamivir carboxylate (OC). OP levels were low at 10 to 77 ng/ml. but OC concentrations were high at 2,600 to 5,000 ng/ml. Conclusions The population normal parameter for half-life OP is 1 hour and for OC it is 3 to 5 hours. A single dose of 150 mg OP is expected to achieve an OP level of 50 to 150 ng/ml and an OC level of 1,000 to 1,500 ng/ml. Our slightly low OP levels are likely to be due to ex vivo hydrolysis in the collection tube due to a lack of esterase inhibitor. The high OC levels are most probably due to reduced renal elimination despite being on haemoiltration. Our concerns were focused on the possibility of viral mutation (subsequently shown to be negative) or poor enteral absorption/activation. What we found was that 150 mg BD produces more than adequate OC levels to treat H1N1 infection. P70 Eicacy and utility of a protocol for pre-emptive antimycotic therapy SG Milanov, G Georgiev, V Todorova, L Kozarov, M Milanov Pirogov Emergency Institute, Soia, Bulgaria Critical Care 2010, 14(Suppl 1):P70 (doi: 10.1186/cc8302) Introduction Invasive candidiasis (IC) is associated with increasing morbidity and mortality in critically ill patients. This, in conjunction with diiculties in diagnosis, underscores the need for novel treatment strategies based on the identiication of signiicant risk factors for IC. The aim of the study was to evaluate the eicacy and safety of a protocol for pre-emptive antimycotic treatment. Methods A randomized prospective controlled trial was carried out in a general ICU for 2 years. After the implication of the inclusion and exclusion criteria, patients were submitted to block randomization and stratiied on the basis of their initial SAPS II expanded score. We have developed a protocol for pre-emptive antimycotic treatment. Having reviewed the current literature, we combined the most signiicant risk factors for IC with tree major clinical criteria for persistent nonbacterial sepsis and assumed this algorithm as an indication for starting pre-emptive therapy. According to the protocol, antimycotic therapy was started on the day of inclusion in the treatment group and only with proven IC in the control group. Initial data were gathered on demographic characteristics of the patients, proven risk factors for IC-related mortality (malnutrition, non-albicans colonization, creatinine clearance) and severity of inlammatory response and organ dysfunction. Dynamics of SIRS and SOFA, subsequent Candida isolates, ventilator-free days, length of ICU stay, outcome and eventual adverse reactions were followed. Results A total of 110 patients (equal in both groups) were enrolled. No statistically signiicant diferences in the basal characteristics of the patients, length of ICU stay and the number of ventilator-free days were found. The delta SOFA score was signiicantly lower in the treatment group (P = 0.019).The in-hospital mortality was 38.2% in the treatment group vs 61.8% in the control group (P = 0.013). The associated with pre-emptive therapy relative risk was 0.62 (95% CI = 0.4 to 0.94). Signiicant diferences between the Kaplan–Meyer estimates of survival were found (log-rank test P = 0.007). A total of 15 (13.6%) adverse reactions were observed among treated patients in both groups which was not associated with higher mortality risk. Conclusions The implementation of the developed protocol reduced the degree of organ dysfunction severity and was associated with signiicant survival beneit. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S26 P71 Amphotericin B used as a continuous infusion is safer J Streefkerk, S Gijsberts, J Ros, J Rommes, P Spronk Gelre Ziekenhuizen, DZ Apeldoorn, the Netherlands Critical Care 2010, 14(Suppl 1):P71 (doi: 10.1186/cc8303) Introduction Many patients in an ICU are intestinal carriers of yeasts with an inherent risk of infections if bowel perforation occurs. Resistance to azoles is increasing, while treatment with conventional amphotericin B (AM-B) is associated with potential toxicity. AM-B given in a continuous 24hour infusion may be less toxic compared with the conventional 4-hour to 6-hour infusion rate of AM-B [1,2]. AM-B given in a continuous 24-hour infusion is only evaluated in a tertiary care setting, with a predominance of immunocompromised patients. We evaluated the feasibility and safety of continuous AM-B treatment in critically patients with suspected or proven yeast or fungal infections. Methods This is an observational retrospective analysis for the side efects in consecutive patients treated with AM-B from January 2003 to December 2008 in our ICU department. During the investigation period patients received amphotericin B: 40 mg/24 hours or a lower dose if the MDRD clearance was less than 60 ml/min. During the treatment the dose was adjusted to the desired therapeutic range of 200 to 1,000 μg/l according to measured plasma levels. Results The mean treatment duration was 12.3 ± 6.3 days with a dose of 32.1 ± 12.2 mg/24 hours. Of the 10 patients who died, seven died after the termination of the AM-B therapy, without signs of an active yeast or fungal infection. Within the irst week three patients died, necropsy was carried out in one case, demonstrating a PCP infection, and in two patients a role of antibiotic failure cannot be ruled out. All other patients with proven yeast or fungal infection demonstrated a clinical recovery of their infection. The AM-B concentration was measured in 113 blood samples, nine samples had a level <200 μg/l and 10 a level >1000 μg/l. Renal impairment, deined as more than 1.5 times the creatinine at the start of the treatment with AM-B, occurred in 9% and was not evaluable in 6% due to unresolving renal replacement therapy dependency at the start of AM-B. None of the evaluated patients developed a creatinine more than 2.0 times the baseline value. Temporary elevation of liver enzymes was seen in 23%, without the need for dose modiication. Hypokalemia (K+ <3.0 mmol/l) was observed in one patient. Conclusions Compared with the conventional infusion rate of AM-B, we conclude that continuous 24-hour infusion seems a feasible and safer treatment alternative in patients with invasive yeast or fungal infections. References 1. 2. Walsch TJ, et al.: N Engl J Med 1999, 340:764-771. Wingard JR, et al.: Clin Infect Dis 1999, 29:1402-1407. P72 Anidulafungin compared with luconazole therapy in critically ill patients DH Kett1, AF Shorr2, AC Reboli3, AC Reisman4, P Biswas4, HT Schlamm4 1 University of Miami/Jackson Memorial Hospital, Miami, FL, USA; 2 Washington Hospital Center, Washington, DC, USA; 3University of Medicine and Dentistry of New Jersey – Robert Wood Johnson Medical School, Camden, NJ, USA; 4Pizer Inc., New York, USA Critical Care 2010, 14(Suppl 1):P72 (doi: 10.1186/cc8304) Introduction The 2009 IDSA Treatment Guidelines for Candidiasis favor an echinocandin for initial treatment of candidemia in patients with severe illness. In a prospective, randomized study anidulafungin resulted in improved global response (GR) and a trend toward improved survival compared with luconazole [1]. Methods Retrospective analysis in patients classiied as severely ill at study entry: treatment initiated in an ICU (Group 1), APACHE II score ≥15 (Group 2) or presence of severe sepsis (Group 3). Within groups, anidulafungin was compared with luconazole for GR rate at the end of intravenous therapy and 14-day and 28-day mortality. Results In Group 1 (n = 89), GR was 63.3% vs 45.0% (95% CI: –2.2 to 38.8); Group 2 (n = 113), GR was 68.3% vs 46.0% (95% CI: 4.3 to 40.2); and Group 3 (n = 118), the GR was 67.7% vs 51.8% (95% CI: –1.6 to 33.5), in patients with MOD (n = 45), the GR was 76.2% vs 29.2% (95% CI: 21.3 to 72.8) anidulafungin versus luconazole, respectively. Across groups, Figure 1 (abstract P72). Global response to treatment. an association with anidulafungin use and lower day 14 mortality was suggested (12.2% to 14.3% for patients receiving anidulafungin vs 19.6% to 28.0% for those receiving luconazole) (P = NS). See Figure 1. Conclusions In patients with severe illness, anidulafungin was associated with greater GR than luconazole, signiicantly so for those with APACHE II score ≥15 or with MOD, supporting the IDSA Guidelines. Reference 1. Reboli AC, et al.: N Engl J Med 2007, 356:2472-2482. P73 Increase in systolic blood pressure and improvement in laboratory parameters following polymyxin B-immobilized iber treatment in septic shock Y Sakamoto1, K Mashiko1, T Obata2, H Matsumoto1, Y Hara1, N Kutsukata1, H Yokota3 1 Chiba Hokusoh Hospital, Nippon Medical School, Chiba, Japan; 2Microbial Chemistry Reaearch Foundation, Tokyo, Japan; 3Nippon Medical School, Tokyo, Japan Critical Care 2010, 14(Suppl 1):P73 (doi: 10.1186/cc8305) Introduction Direct hemoperfusion using a polymyxin B-immobilized iber column (DHP-PMX; Toray Industries Inc., Tokyo, Japan) was irst developed in 1994 and has since been used for the treatment of septic shock. Methods A total of 47 patients with septic shock who received DHPPMX for 2 to 6 hours were retrospectively reviewed to examine any improvement in sepsis-related factors after DHP-PMX and to analyze the relationship between any such improvement and increase in SBP. Figure 1 (abstract P73). Changes in systolic blood pressure in patients treated with DHP-PMX in whom HMBG-1 level increased. P <0.0001. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 In addition, we analyzed the efectiveness of long-term DHP-PMX (5 to 6 hours) with respect to improvement in sepsis-related factors. Results N-arachidonoylethanolamine (AEA), 2-arachidonoyl glycerol (2-AG), and plasminogen activator inhibitor-1 (PAI-1) were signiicantly improved after DHP-PMX treatment. SBP increased signiicantly in the group showing improved high mobility group box protein 1 (HMGB-1) level (P <0.0122). AEA, 2-AG and HMGB-1 were improved in all four patients who were treated with long-term DHP-PMX. Conclusions We observed a relationship between hemodynamic improvement and a decrease in serum HMGB-1 level in septic shock patients treated with DHP-PMX. We suggest that long-term DHP-PMX improves sepsis-related factors. References 1. Sakamoto Y, et al.: ASAIO J 2007, 53:646-650. P74 Selection of acute blood puriication therapy according to lipid mediator adsorption and blood puriication in patients with septic shock Y Sakamoto1, K Mashiko1, T Obata2, H Yokota3 1 Chiba Hokusoh Hospital, Nippon Medical School, Chiba, Japan; 2Microbial Chemistry Research Foundation, Tokyo, Japan; 3Nippon Medical School, Tokyo, Japan Critical Care 2010, 14(Suppl 1):P74 (doi: 10.1186/cc8306) Introduction Direct hemoperfusion using a polymyxin B-immobilized iber column (DHP-PMX) has been used for the treatment of septic shock. As an alternative method for acute blood puriication therapy, continuous venovenous hemodiailtration (CVVHDF) has been reported to be an efective clinical treatment for critically ill patients; however, the optimal column for performing CVVHDF remains controversial. On the other hand, recently, one of the lipid mediators, endocannabinoids (N-arachidonoylethanolamine (AEA) and 2-arachidonoyl glycerol (2-AG)) have been reported with a blood pressure decreased efect. Methods We investigated 14 polymethylmethacrylate (PMMA) membrane hemoilters and three polyacrylonitrile (PAN) membrane hemoilters after use in patients with septic shock. Therefore, in clinical study, we used CVVHDF after DHP-PMX to treat 32 patients with septic shock. To determine the optimal acute blood puriication therapy, we subsequently divided the patients into two groups: group A underwent CVVHDF using a PMMA membrane hemoilter after undergoing DHP-PMX (n = 25); group B underwent CVVHDF using a PAN membrane hemoilter after undergoing DHP-PMX (n = 7). In addition, the levels of endocannabinoids (AEA, 2-AG) were measured. The severity scores and the improvement of endocannabinoids were compared between the two groups. Results Endocannabinoids (AEA, 2-AG) were adsorbed more in the PMMA column (AEA; 506.3 ± 680.2 ng/column, 2-AG; 23.0 ± 38.5 μg/column) than in the PAN column (AEA; 1.5 ± 0.7 ng/column, 2-AG; 0.1 ± 0.1 μg/column). The average Acute Physiology and Chronic Health Evaluation (APACHE) II score and the average sepsis-related organ failure assessment (SOFA) score did not difer signiicantly between the two groups. Group A showed a better outcome compared with Group B (P = 0.05). In addition, only group A showed a signiicant improvement in the blood AEA level on day 1 (P = 0.0185). Conclusions Our study suggests that the PMMA column might be the better column for performing CVVHDF after DHP-PMX treatment, as suggested by the adsorption and blood puriication of endocannabinoids. Reference 1. Sakamoto Y, et al.: ASAIO J 2008, 54:129-132. S27 biomarkers, such as Pro-ET1 and MR-ProADM, were shown to correlate with CAP severity [2]. We aimed to compare the diagnostic accuracy to predict mortality and ICU admission of clinical severity scores, biomarkers and their combination. Methods Nine hundred and twenty-ive CAP patients enrolled in the ProHOSP trial [3] were analyzed by assessing clinical severity scores (SMARTCOP, PSI, CURB65) and biomarker levels (PCT, MR-ProADM, Pro-ET1). Receiver operating characteristic curves for 30-day mortality and ICU admission were used to calculate and compare the diferent predictive values. Results The AUC for the prediction of 30-day mortality was 0.84 with SMART-COP, 0.82 with PSI, 0.72 with CURB65, 0.59 with PCT, 0.75 with MR-ProADM and 0.75 with ProET1. ICU admission was predicted best by SMART-COP (AUC 0.83), compared with the other severity scores and biomarkers (PSI: 0.68, CURB65: 0.65, PCT: 0.7, Pro-ET1: 0.73, ProADM: 0.72). The combination of SMART-COP and MR-ProADM was superior to SMARTCOP alone (AUC 0.84, P = 0.04). Conclusions The combination of MR-ProADM with SMART-COP signiicantly improved the prediction of ICU admission. Prognostic biomarkers should complement the clinical assessment of patients with LRTI to improve allocation of healthcare resources to high-risk patients. References 1. 2. 3. P76 Current progress in pneumonia research T Smelaya1, V Moroz1, A Goloubev1, L Salnikova2, A Rubanovich2 1 V.A. Negovsky Research Institute of General Reanimatology RAMS, Moscow, Russia Federation; 2N.I. Vavilov Research Institute of General Genetics, Moscow, Russia Federation Critical Care 2010, 14(Suppl 1):P76 (doi: 10.1186/cc8308) Introduction Diagnosis and treatment of acute pneumonia (Pn) is a problem of high signiicance in modern medicine. The incidence of complicated and lethal acute Pn has increased [1]. Candidate genes are of great importance in the course of acute diseases and their complications. Cytokines and xenobiotic detoxication genes are the most investigated. The aim of the investigation was to study genetic predisposition to acute Pn. Methods Results of the associative DNA polymorphism studies in 243 patients with acute community-acquired Pn are presented; 178 healthy individuals formed a control group. Genetic variability of the candidate loci was studied: renin–angiotensin ACE system gene, chemokine receptor CCR5 gene and four genes controlling xenobiotic detoxiication (CYP1A1, GSTM1, GSTT1, GSTP1). Multiplex polymerase chain reaction was utilized for genotyping of insertion–deletion polymorphism on loci ACE (287 nucleotide pairs) and CCR5 (deletion of 32 nucleotide pairs). The odds ratio index was used to describe the degree of association of the genotypes with the diseases. Statistical analysis was done by means of Fisher’s exact test and the online program SNPStats (http://bioinfo.iconcologia.net). Results An increased predisposition to Pn development was registered in homozygotes in deletion at the ACE locus (OR = 1.8; P = 0.013), positive genotypes of the GSTM1 locus (OR = 1.7; P = 0.010) and homozygotes in allele 606T of the CYP1A1 gene (OR = 1.6; P = 0.020). Conclusions A combination of positive genotypes of the GSTM1 locus and homozygotes in allele 606T of the CYP1A1 gene (OR = 1.9, P = 0.006; incidence in controls >20%) presented with a most efective prognostic power. Reference 1. P75 Prognostic assessment in community-acquired pneumonia by pneumonia severity scores and biomarkers F Dusemund1, W Albrich1, P Schuetz2, B Müller1 1 Kantonsspital Aarau, Switzerland; 2University Hospital Basel, Switzerland Critical Care 2010, 14(Suppl 1):P75 (doi: 10.1186/cc8307) Introduction Classical biomarkers like C-reactive protein (CRP) or the leucocyte count are only inaccurate tools for predicting the severity of community-acquired pneumonia (CAP). Procalcitonin (PCT) was found to predict 28-day mortality in CAP (area under the curve (AUC) 0.8) similar to the combination of PCT and CRB65 score (AUC 0.83) [1]. Novel prognostic Krüger S, et al.: Eur Respir J 2008, 31:349-355. Schuetz P, et al.: BMC Inf Dis 2008, 8:22-30. Schuetz P, et al.:: JAMA 2009, 302:1059-1066. Sinopalnikov AI, et al.: Military Med J 1996, 2:30-33. P77 Bacterial colonization and infections of the lower respiratory tract in an interdisciplinary ICU M Sartzi, M Agraiotis, P Peppa, F Nanu, M Charitidi, I Basiliadis, G Kallitsi, M Michalia, P Clouva-Molyvdas General Hospital Thriassio Elefsinas, Magoula, Greece Critical Care 2010, 14(Suppl 1):P77 (doi: 10.1186/cc8309) Introduction Tracheal intubation and mechanical ventilation are often associated with infection of the lower respiratory tract (LRT). The morbidity Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 associated with the progression of airway colonization (AC) to ventilatorassociated tracheobronchitis (VAT) and from VAT to ventilator-associated pneumonia (VAP) has been analyzed but not been fully elucidated. We endeavored to study the relationship between AC and development of infections (VAT and VAP) of the LRT in ICU patients. Methods Retrospective study of 400 consecutive ICU patients ventilated >48 hours in the past 4 years. Patients age, gender, APACHE II, prior illness, cause of admittance, length of stay (LOS), time of mechanical ventilation (MV), outcome, time of appearance of AC and infection of the LRT were registered. MODS and CPIS were measured at onset of infection (VAT– VAP) and 3 days after. MODS was also calculated on the day AC appeared. Bronchial secretions were cultured at admission, at least once a week and whenever there was a change in the amount and quality of bronchial secretions or clinical infection was suspected. The Mann–Whitney test was used for statistical analysis and statistical signiicance was set at P <0.05. Results From the 400 studied patients 68 (17%) were colonized and 153 (48.25%) developed infections: 54 (13.5%) VAT and 99 (24.7%) VAP. Colonization appeared after 3.1 ± 0.8 days of ICU admission exclusively with Gram-negative microorganisms. Twenty-ive (36.7%) of the colonized patients developed infections of the LRT (with the same pathogen): 8 (11.7%) VAT after 4.6 ± 2.7 days and 17 (25%) were diagnosed with VAP after 9.8 ± 1.8 days. From the eight VAT patients, four developed VAP (50%) after 5.4 ± 0.4 days. None of the colonized patients died. The colonized patients who developed infections were elderly (P <0.05), more severely ill (P <0.04) and had at the time of infection a diagnosis higher temperature (P <0.01), more severe leukocytosis (P <0.02) but not statistically signiicant organ dysfunction (P >0.3). The appearance of VAP caused more severe organ dysfunction (P <0.002), longer MV duration (P <0.01) and longer LOS (P <0.001) but did not inluence mortality. On the day of AC detection MODS was 2.4 ± 0.5, on VAT detection MODS was 4.8 ± 0.9 and on VAP appearance MODS was 9.6 ± 0.7. CPIS at VAT detection was 3.9 ± 0.9 and at VAP detection 6.1 ± 0.5 (day I) and 7.2 ± 0.8 (on day III). Conclusions AC resulted in LRT infections in only one-third of our patients and the majority of LRT infections are not preceded by AC. P78 Rehydration does not afect pulmonary immune responses to inluenza or susceptibility to secondary bacterial pneumonia RD Sanders1, A Godlee1, JC Goulding1, M Maze2, T Hussell1 1 Imperial College London, UK; 2UCSF, San Francisco, CA, USA Critical Care 2010, 14(Suppl 1):P78 (doi: 10.1186/cc8310) Introduction In our murine model of inluenza, signiicant weight loss occurs up to day 7 post-infection [1]. We sought to determine whether weight loss from inluenza could be altered by rehydration and whether this afects pulmonary immune responses. Methods Adult BALB/c mice were infected with X31 (H3N2) inluenza (1:80) via the intranasal route and randomized to intraperitoneal rehydration with 20 ml/kg compound sodium lactate (CSL), normal saline (NS) or no rehydration (NR) starting on day 3 following infection and continued for 4 days (n = 5/group). On day 7, mice were challenged with 1 x 106 Streptococcus pneumoniae (serotype 2). Two further cohorts of mice were challenged with diferent doses of inluenza and rehydrated from day 3 to 7 to investigate pulmonary immune responses in the absence of bacteria. Mice were infected with 1:80 (n = 10/group) inluenza and rehydrated once daily or 1:60 (n = 5/group) inluenza and rehydrated twice (1:60) daily with 20 ml/kg CSL or not. Daily weight, survival following secondary bacterial pneumonia, number of colony-forming units (48 hours after bacterial challenge) from peripheral blood, lung, and nasal wash and cellularity in lung compartments were measured. Results Rehydration did not afect weight loss following 1:80 inluenza infection (naïve mice (+0.3 ± 0.4 g), inluenza plus NR (–1.58 ± 0.4 g), inluenza plus CSL (–1.1 ± 0.7 g) and inluenza with NS (–1.3 ± 0.4 g)). A repeat experiment with CSL once daily or twice daily did not alter weight loss compared with NR (P >0.05). Survival or CFU counts following bacterial pneumonia did not difer between the groups (P >0.05). The total number or activational status of bronchoalveolar, lung macrophages/monocytes and lymphocytes was not afected by rehydration following inluenza infection or 48 hours following bacterial pneumonia (P >0.05; P <0.05 vs naïve mice). Conclusions Rehydration does not afect immunity or pathophysiology in a murine inluenza infection model. Assuming these results can be S28 extrapolated to the clinical setting, our indings support the use of conservative luid resuscitation strategies in patients with inluenza. Reference 1. Snelgrove et al.: Nat Immunol 2008, 9:1074-1083. P79 Bacteremic nosocomial pneumonia cases from the ATTAIN studies E Rubinstein1, SL Barriere2, FC Genter2, GR Corey3, C Luna4, A Lentnek5, ME Stryjewski6 1 University of Manitoba, Winnipeg, Canada; 2Theravance, Inc., South San Francisco, CA, USA; 3DCRI, Durham, NC, USA; 4University of Buenos Aires, Argentina; 5Wellstar Infectious Disease, Marietta, GA, USA; 6CEMIC, Buenos Aires, Argentina Critical Care 2010, 14(Suppl 1):P79 (doi: 10.1186/cc8311) Introduction Bacteremic pneumonia is associated with worse outcome including higher mortality. The ATTAIN program compared telavancin (TLV), a lipoglycopeptide antibiotic, with vancomycin (VAN) for treatment of nosocomial pneumonia (NP) due to Gram-positive pathogens including MRSA. This subgroup analysis examined the baseline characteristics and clinical outcomes in bacteremic HAP cases. Methods ATTAIN 1 and 2 were methodologically identical, randomized, double-blind, phase 3 studies. Adult patients with NP due to presumed or conirmed Gram-positive pathogens were randomized (1:1) to TLV 10 mg/ kg intravenously every 24 hours or VAN 1 g intravenously every 12 hours (adjusted per site-speciic guidelines) for 7 to 21 days. The modiied alltreated (MAT) population consisted of patients who received ≥1 dose of study medication and who had a respiratory pathogen recovered from baseline cultures. Bacteremic NP was deined by the identiication of a pneumonia-causing pathogen in the blood or of the same pathogen in lung and blood with identical susceptibility proiles. Clinical outcomes were assessed at test-of-cure (TOC) 7 to 14 days after end of study treatment. Results All MAT patients with bacteremic NP (n = 73) were included in this analysis. At baseline, more TLV patients than VAN patients were in the ICU (TLV 74%, VAN 62%) and had ventilator-associated pneumonia (TLV 59%, VAN 44%); APACHE II scores were similar between groups (mean ± SD, TLV 16 ± 6, VAN 17 ± 6). S. aureus was the most common pathogen (TLV 76%, VAN 69%) and included MRSA (TLV 41%, VAN 49%). Cure rates for TLV and VAN were 44% and 36%, respectively (diference TLV – VAN (95% CI) = 7.3% (–15.9%, 30.5%)). On-study mortality was similar, 41% in each treatment group. Incidences of adverse events (AE) were similar between groups, except for nausea (TLV 21%, VAN 3%) and vomiting (TLV 15%, VAN, 0%). Proportions of patients who discontinued the study medication due to AEs were similar (TLV 12%, VAN 13%). Conclusions TLV and VAN had similar cure rates in a subgroup of ATTAIN patients with bacteremic NP. The safety proiles of TLV and VAN were mostly comparable in these patients. P80 Late ventilator-associated pneumonia: analysis of baseline characteristics and clinical outcomes in the ATTAIN studies E Rubinstein1, SL Barriere2, FC Genter2, GR Corey3, PC Lee4, T Lalani3 1 University of Manitoba, Winnipeg, Canada; 2Theravance, Inc., South San Francisco, CA, USA; 3DCRI, Durham, NC, USA; 4Baystate Medical Centre, Springield, MA, USA Critical Care 2010, 14(Suppl 1):P80 (doi: 10.1186/cc8312) Introduction Pneumonia is a leading cause of death associated with hospital-acquired infections. Late ventilator-associated pneumonia (VAP), deined as disease onset after ≥4 days of mechanical ventilation, is associated with worse outcomes than other forms of hospital-acquired pneumonia (HAP). Methods ATTAIN 1 and 2 were methodologically identical, randomized, phase 3 studies of telavancin (TLV) 10 mg/kg intravenously every 24 hours vs vancomycin (VAN) 1 g intravenously every 12 hours for treatment of HAP, including VAP. VAN doses could be adjusted per investigative site guidelines. Clinical outcome was assessed at the test-of-cure (TOC) visit 7 to 14 days after the end of study treatment. Baseline characteristics, outcomes, and safety in the late VAP sub-group were analyzed in the Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S29 these indexes must be performed to diagnose ARDS in NPn. Physiological limits of the PVPI require an additional investigation due to an insuicient diagnostic value. Volumetric indexes of central hemodynamics should be measured to conirm the noncardiogenic nature of pulmonary edema. Figure 1 (abstract P80). modiied all-treated population (MAT; patients with baseline respiratory pathogen(s) who received ≥1 dose of study medication) and the microbiologically evaluable population (ME; protocol adherent MAT patients with baseline Gram-positive pathogen(s)). Patients with mixed Gram-positive/Gram-negative infections were excluded in this analysis. Results A total of 197 late VAP cases were analyzed. Baseline characteristics, including the APACHE II scores, were balanced between the treatment groups (Figure 1). At least one adverse event (AE) was reported by 95% (106/112) and 93% (79/85) of MAT patients in the TLV and VAN groups, respectively, and 21% (23/112) of the TLV group and 22% (19/85) of the VAN group died during the study. Conclusions In this exploratory sub-group analysis, numerically higher cure rates were observed for TLV than for VAN in patients with late VAP. Incidences of reported AEs and mortality rates were similar between the TLV and VAN groups. P81 On the diagnosis of acute respiratory distress syndrome in nosocomial pneumonias A Kuzovlev, VV Moroz, AM Goloubev V.A. Negovsky Research Institute of General Reanimatology, Moscow, Russia Federation Critical Care 2010, 14(Suppl 1):P81 (doi: 10.1186/cc8313) Introduction Clinical practice deals highly frequently with patients presenting a concomitant occurrence of acute respiratory distress syndrome (ARDS) and nosocomial pneumonia (NPn). Timely diagnosis of ARDS and NPn in such circumstances is problematic, but it provides a possibility of diferential treatment. The aim of the investigation was to elucidate the value of the oxygenation index (OI), extravascular lung water index (EVLWI), pulmonary vascular permeability index (PVPI) and central hemodynamics indexes in the diagnosis of ARDS in NPn. Methods Thirty-eight cancer and severely traumatized patients were enrolled in the prospective clinical investigation. The patients were split into three groups according to the ARDS and NPn diagnostic criteria: group 1 (ARDS + NPn), group 2 (NPn), group 3 (no ARDS, no NPn). ARDS was diagnosed by means of the Lung Injury Score (LIS), the American– European Consensus Conference on ARDS criteria (1992), and the criteria of the V.A. Negovsky Research Institute of General Reanimatology (2006). All patients were investigated with a complex protocol, key elements of which were EVLWI, PVPI and central hemodynamics indexes measured by the transpulmonary thermodilution (Pulsion PiCCO plus, Pulsion Medical Systems, Germany). The data were analyzed by Statistica 7.0 (M ± SD, Newman–Keuls test, correlations). P <0.05 was considered statistically signiicant. Results Patients of group 1 on the day of enrollment presented with a signiicantly lower OI (160.9 ± 51.7 mmHg vs 239.5 ± 96.7 mmHg) and static pulmonary compliance (46.3 ± 13.7 ml/water cm vs 72.4 ± 23.1 ml/water cm) and signiicantly higher EVLWI (12.7 ± 4.7 ml/kg vs 7.6 ± 1.6 ml/mg) and LIS (2.22 ± 0.67 scores vs 1.68 ± 0.58 scores) in comparison with group 2 patients. The patients of group 2 presented with an EVLWI within the physiological limits over the whole investigation period. PVPI calculated by three existing methods was available within the physiological limits even in the patients with a profound pulmonary edema. There were no signiicant diferences between the groups in central hemodynamics parameters. Conclusions The OI, EVLWI, static pulmonary compliance and LIS made it possible to timely diagnose ARDS in NPn. Patients with NPn without ARDS presented with EVLWI within the physiological limits. A complex analysis of P82 Genetic variability at the surfactant proteins A and D in susceptibility and severity of pneumonia J Solé-Violán1, M Garcia-Laorden1, F Rodriguez de Castro1, O Rajas2, J Blanquer3, L Borderías4, P Saavedra5, J Aspa2, M Briones3, J Marcos-Ramos6, E Herrera-Ramos1, J Ferrer1, I Sologuren1, J Rello7, C Rodriguez-Gallego1 1 Hospital Dr Negrín, Las Palmas de Gran Canaria, Spain; 2Hospital de la Princesa, Madrid, Spain; 3Hospital Clínico, Valencia, Spain; 4Hospital San Jorge, Huesca, Spain; 5University of Las Palmas de Gran Canaria, Las Palmas, Spain; 6Hospital General de Lanzarote, Spain; 7Joan XXIII University Hospital, Tarragona, Spain Critical Care 2010, 14(Suppl 1):P82 (doi: 10.1186/cc8314) Introduction Genetic variability of the pulmonary surfactant proteins A and D may afect clearance of microorganisms and the extent of the inlammatory response. The genes of these collectins (SFTPA1, SFTPA2 and SFTPD) are located in a cluster at 10q21-24, near to the gene coding for mannose-binding lectin (MBL2), another collectin involved in innate immunity. The aim of this study was to evaluate the association of variability at SFTPA1, SFTPA2 and SFTPD with susceptibility to and severity of community-acquired pneumonia (CAP). Another objective was to evaluate the existence of linkage disequilibrium among SFTPA1, SFTPA2, SFTPD and MBL2. Methods Nonsynonymous polymorphisms of SFTPA1, SFTPA2, SFTPD and MBL2 were analysed in 682 CAP patients and 769 controls. Haplotypes were inferred and linkage disequilibrium (LD) was characterized. The efect of genetic variability on SP-A and SP-D serum levels was studied. Results Haplotypes SFTPA1 6A2 (P = 0.0009), SFTPA2 1A0 (P = 0.0017), and SFTPA1-SFTPA2 6A2-1A0 (P = 0.0005) were under-represented in patients, whereas haplotypes SFTPA2 1A10 (P = 0.00007) and SFTPA1-SFTPA2 6A3-1A (P = 0.00065) were over-represented. We observed the existence of LD among the studied genes. Chromosomes carrying the SFTP-D aa11-C allele with 6A2-1A0 and the XA variant of MBL2 were found to be even more under-represented in patients (P = 0.00008). 1A10 and 6A-1A were associated with higher mortality, and also with multiorgan dysfunction syndrome (MODS) and acute respiratory distress syndrome (ARDS), respectively. SFTPD aa11-C allele was associated with development of MODS and ARDS. Conclusions We report for the irst time an association between genetic variants of SFTPA1, SFTPA2 and SFTPD with the susceptibility, severity and outcome of pneumonia. P83 Successful strategy to reduce ventilator-associated pneumonia AL Manoel, Í Boszczowski, AH Andrade, L Bierrenbach, E Taira, AC Baruzzi Hospital Municipal Dr. Moysés Deutsch, São Paulo, Brazil Critical Care 2010, 14(Suppl 1):P83 (doi: 10.1186/cc8315) Introduction VAP rates in Brazil are higher than those related in Europe and USA. The study objective was to examine the efect of the Institute for Healthcare Improvement’s ventilator bundle plus oral decontamination with chlorhexidine (ODC) in the incidence of VAP in an ICU. Methods The study was conducted in a 20-bed, medical-surgical ICU. Criteria for nosocomial pneumonia are those from the CDC. Strategy was to implement the IHI’s ventilator bundle plus ODC. The goals were the ICU team adhesion of 80% achieved in the ninth month after bundle implementation and 98% after 1 year of follow-up. These measures included ive strategies to prevent ventilator-associated pneumonia: 30 to 45° elevation of the head of the bed, adequate sedation level (Ramsay 2 or 3), DVT/PE prevention, peptic ulcer prophylaxis and oral decontamination with chlorhexidine 0.12%. From February 2009 onwards, the ICU nursing staf and ICT performed a daily checklist in order to observe the ive issues accomplishment. If any item was found to be inadequate it was promptly corrected. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S30 P85 Oral chlorhexidine to prevent nosocomial pneumonia in critically ill patients: a systematic review and meta-analysis RJ Pugh, P Rathbone Glan Clwyd Hospital, Rhyl, UK Critical Care 2010, 14(Suppl 1):P85 (doi: 10.1186/cc8317) Figure 1 (abstract P83). Proportion of bundle adhesion and density of incidence of ventilator-associated pneumonia. Results In February and September, adhesion to the whole bundle was 9% and 86%, respectively (P <0.001) (Figure 1). VAP density was proportionally lower to bundle adhesion in the same period, 20 per 1,000 ventilation/day and 4.5, respectively. Conclusions Initial VAP rates were extremely high even for Brazilian benchmarks. Although we could not implement expensive technologies like continuous aspiration of subglottic secretions, the ICU team and ICT eforts were crucial for satisfactory results, as well the administrative board support, which turned this issue into an institutional priority. Our goals are to reduce even more, implementing the ‘ventilator bundle – getting to zero’ program, and maintaining a continued efort to sustain these results. P84 Ventilator-associated pneumonia rate and ventilator bundle compliance in a district general hospital E Winkley, E Sykes Northumbria Healthcare NHS Trust, Ashington, UK Critical Care 2010, 14(Suppl 1):P84 (doi: 10.1186/cc8316) Introduction An observational study to establish the incidence of ventilator-associated pneumonia (VAP), and ventilator care bundle (VCB) compliance. Neither has previously been quantiied at our institution. VAP is a nosocomial pneumonia presenting in patients mechanically ventilated for ≥48 hours [1]. Use of microbiological data in conjunction with the Clinical Pulmonary Infection Score (CPIS) improves VAP diagnostic speciicity [1]. VCBs reduce VAP rates, in some cases to zero. The Department of Health VCB is one such collection of evidence-based interventions [2]. Methods A 3-month (April 2009 to June 2009) prospective observational study, in an eight-bed critical care unit in a district general hospital. All mechanically ventilated patients, age ≥18, intubated >48 hours were included. Pregnant or immunosuppressed patients were excluded. Patients treated with antibiotics for suspected or conirmed VAP were identiied. CPIS was calculated on day 0 and day 3 of treatment. VCB compliance was recorded weekly in all patients. Results A total of 190 ventilator-days were identiied with no cases of VAP. The VAP rate per 1,000 ventilator-days is 0. Sixty-nine percent of cases achieved 100% VCB compliance. Four of the six VCB elements were 100% compliant (Table 1). All incidents of noncompliance had valid clinical reasons. Conclusions The VAP rate at Wansbeck General Hospital is zero. Compliance with a recognised VCB is high. The previous VAP rate was unknown. The impact of the VCB and the short study duration are unclear. Continuous data collection has been implemented to establish whether such results are representative and sustainable. Use of the CPIS to limit inappropriate antibiotic in suspected VAP is planned. References 1. 2. Calandra T, et al.: Crit Care Med 2005, 33:1538-1548. [http://www.clean-safe-care.nhs.uk/index.php?pid = 4] Introduction This systematic review aims to evaluate evidence from randomised controlled trials (RCTs) for oral chlorhexidine in preventing nosocomial pneumonia in intubated mechanically ventilated critically ill adults. Use of oral chlorhexidine appeals since it should reduce bacterial aspiration from the orophayrnx. A number of RCTs have recently been published on this topic. Methods Search of Medline, Embase, Cochrane library, grey literature registers, conference proceedings and reference lists for RCTs comparing chlorhexidine with placebo or standard care for prevention of pneumonia in the critically ill. Outcomes: episode of nosocomial respiratory tract infection (RTI), mortality, duration of mechanical ventilation (MV) and length of ITU stay (ITU LOS). Review Manager 4.2 (Nordic Cochrane Centre) was used for data synthesis. Efect estimates (odds ratio for dichotomous and weighted mean diference for continuous data) were calculated using a random efects model. Results Fourteen studies were identiied, three involving patients undergoing cardiac surgery (1,841 patients) and 11 involving patients in noncardiothoracic ITUs (1,497 patients; see Table 1). Five studies (including two cardiac studies) found a signiicant reduction in episodes of nosocomial RTI in the chlorhexidine-treated group versus placebo or standard care. Pooled data indicated a signiicant reduction in nosocomial RTI in the treatment group among all patients, and among cardiac and noncardiac sub-groups (odds ratio 0.57 (95% CI 0.42 to 0.77), 0.52 (0.37 to 0.75) and 0.6 (0.4 to 0.89), respectively). However, no signiicant diferences in mortality, duration of mechanical ventilation or ITU stay were demonstrated. Signiicant heterogeneity (I2 statistic >40%) was detected for all outcomes except mortality. Table 1 (abstract P85). Efect estimates Number of studies Participants Efect 14 3,338 OR 0.57 Mortality 11 3,233 OR 1.2 MV days 6 noncardiac 1,027 WMD +1.34 ITU LOS days 4 noncardiac 702 WMD –0.51 RTI Conclusions Use of oral chlorhexidine is associated with reduction in nosocomial respiratory tract infection in intubated mechanically ventilated critically ill adults. P86 Impact of routine multiple site decontamination in intubated patients on ICU-acquired infections C Camus, S Lavoué, A Gacouin, S Marque, A Gros, Y Le Tulzo Hôpital Pontchaillou, Rennes, France Critical Care 2010, 14(Suppl 1):P86 (doi: 10.1186/cc8318) Introduction We have shown that a the combination of selective digestive decontamination with topical antibiotics (SDD) and a decontamination regimen using nasal mupirocin with chlorhexidine bodywashing (M/C) markedly reduced acquired infections (AI) in intubated patients as compared with SDD alone, M/C alone or none [1]. We report the surveillance of AI in our ICU before and after the implementation of multiple site decontamination (MSD) as a routine prevention procedure. Table 1 (abstract P84). Ventilator care bundle compliance Element Compliance (%) 30 to 40° head elevation Sedation hold DVT prophylaxis GI prophylaxis Humidiication Tubing management All elements 100 88 81 100 100 100 69 Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Methods MSD was implemented in June 2007. We compared the incidence rates of AI (expressed per 1,000 patient-days (‰) or per 1,000 device-days for device-related AI) between the last 1-year period before (period A, 7,723 patient-days) and the irst 1-year period after (period B, 7,646 patient-days) MSD use was started. Results In period B (MSD) versus period A (no MSD), there was a reduction in the rates of total AI (9.4‰ vs 23.6‰), bloodstream infections (1.0‰ vs 4.0‰), ventilator-acquired pneumonia (5.6‰ vs 19.1‰) (all P <0.01), and to a less extent catheter-related urinary tract infection (1.0‰ vs 2.2‰, P = 0.11). Multivariate analysis with the Cox regression model showed that period A (OR 2.34 (1.64 to 3.20)) and the presence of a central venous catheter (OR 2.07 (1.22 to 3.57)) were the two independent risk factors for AI. In period B, there was a statistically signiicant reduction in the rates of AI involving S. aureus (1.0‰ vs 3.0‰), coagulase-negative staphylococci (0.4‰ vs 1.3‰), Candida (0.4‰ vs 1.3‰) and aerobic Gram-negative bacilli (5.0‰ vs 15.8‰), especially Enterobacteriaceae (3.4‰ vs 9.4‰), Pseudomonas aeruginosa (1.4‰ vs 3.9‰), S. maltophilia (0 vs 1.7‰) and Acinetobacter sp. (0 vs 0.8‰) (all P ≤0.05). MRSA AI rates were also lower (0.3‰ vs 0.9‰, NS) and no AI due to VRE occurred during both period. The rates of AI involving antimicrobial-resistant Enterobacteriaceae were lower in period B for 12 antimicrobials tested, especially for ticarcillin (2.1‰ vs 6.5‰), ticarcillin/ clavulanate (0.8‰ vs 4.0‰), cefotaxime (0.3‰ vs 2.2‰) and colistin (0.5‰ vs 1.8‰) (all P ≤0.02). Similar indings were observed for antimicrobialresistant P. aeruginosa although diferences were not signiicant. Overall, the rate of AI involving organisms deined as multidrug-resistant (MDROs) markedly decreased in period B (2.5‰ vs 9.1‰, P <0.001). Conclusions Routine use of MDS was associated with a strong reduction in ICU AI. The reduction was consistently observed for all principal classes of pathogens, including MDROs. No new MDRO emerged. Reference 1. S31 P88 Time course of RT-PCR positivity in H1N1-induced ARDS E Mannelli1, M Murtigni1, M Andreani1, S Cianferoni1, D Colosimo1, G Zagli2, M Bonizzoli2, A Azzi3, A Peris2 1 Postgraduate School of Anesthesia and Intensive Care, University of Florence, Italy; 2Careggi Teaching Hospital, Florence, Italy; 3University of Florence, Italy Critical Care 2010, 14(Suppl 1):P88 (doi: 10.1186/cc8320) Introduction The aim of this study was to analyze the correlation between antiviral therapy eicacy and the negative proile of the RT-PCR made on pharyngeal swab, subglottic aspiration, and bronchoalveolar lavage in patient afected by ARDS caused by H1N1 infection. Methods A prospective analysis was performed on 11 patients admitted to the ICU of a tertiary referral center (Careggi Teaching Hospital, Florence, Italy). All patients underwent daily RT-PCR monitoring on pharyngeal swab, subglottic aspiration, and bronchoalveolar lavage. All patients were treated with oral administration of oseltamivir (75 mg twice daily) and inhaled zanamivir (10 mg twice daily) since ICU admission. Six patients were treated with extracorporeal membrane oxygenation (ECMO) due to their critical respiratory conditions. Two of them resulted co-infected by legionella pneumophila. Results As shown in Figure 1, RT-PCR from pharyngeal swab at ICU admission failed to demonstrate the viral infection in four patients, whereas RT-PCR from bronchoalveolar lavage had a sensibility of 100%. Similarly, the time course showed that RT-PCR from pharyngeal swab resulted negative in an average time of 3 days after therapy start, while RT-PCRs from bronchoalveolar lavage continued to permit infection monitoring and therapy regimen conduction. None of RT-PCRs on subglottic aspiration samples resulted positive. All patients recovered and were discharged alive from ICU in spontaneous breathing. Camus C: Crit Care Med 2005, 33:307-314. P87 Ventilator-associated pneumonia caused by Pseudomonas aeruginosa and respiratory colonization by Candida spp. F Antonicelli, R Festa, F Idone, F Di Muzio, R Maviglia, M Antonelli Università Cattolica del Sacro Cuore, Roma, Italy Critical Care 2010, 14(Suppl 1):P87 (doi: 10.1186/cc8319) Introduction This study aims to test the association of an increased mortality in critically ill patients with ventilator-associated pneumonia (VAP) caused by Pseudomonas aeruginosa in patients with a previous respiratory tract colonization by Candida spp. compared with that of patients with a VAP by P. aeruginosa without Candida spp. isolation. Methods A retrospective study on all 5,236 critically ills patients admitted to the ICU of a university hospital from 2001 to 2008, of which 1,097 received mechanical ventilation and in whom Pseudomonas and/or Candida were isolated in quantitative cultures from the Mini-BAL [1]. Results P. aeruginosa and Candida spp. were present at the same time in 295 patients (P-C group), P. aeruginosa only in 92 patients (P group) and Candida spp. only in the remaining 710 patients (C group). SAPS II was 44.27 ± 14.8 (mean ± SD), 39.07 ± 14.61 and 39.07 ± 14.61, respectively, for P-C, P and C groups. The SAPS II score of the C group was signiicantly higher than the P group (P <0.05), the SAPS II score of the C group was higher than the P-C group (P >0.05), and the SAPS II score of the P group was lower than the P-C group (P >0.05). The population with Candida spp. isolation alone was older (70.25 years vs 63.17 (group P-C) and 60.22 (group P), P <0.05). The group with Pseudomonas associated with Candida spp. had a mortality rate higher than the P group (57.96% vs 6.05%, P <0.05). The length of stay in the ICU of patients with Candida spp. and P. aeruginosa was not diferent from the group who had P. aeruginosa alone (26.22 ± 31.80 vs 29.15 ± 25.66, P >0.05). Duration of hospitalization in the group with only P. aeruginosa was longer than the other two groups (79.38 days vs 51.85 of the group P-C and 28.40 of group C, P <0.05). Conclusions Candida colonization seems to increase the risk for Pseudomonas infection [2]. Patients who developed VAP due to P. aeruginosa with previous colonization of the respiratory tract by Candida spp. were older, with a higher SAPS II score and had a high mortality. References 1. 2. Koenig SM, Truwit JD: Clin Microbiol Rev 2006, 19:637-657. Azoulay E, et al.: Chest 2006, 129:110-117. Figure 1 (abstract P88). Time course of RT-PCR positivity for H1N1 infection. Conclusions In our experience, the most reliable method to diagnose and monitor H1N1 infection was RT-PCR from bronchoalveolar lavage, since pharyngeal swab do not ofer enough sensibility, either for antiviral therapy initiation or for antiviral therapy management. Samples from subglottic aspiration can be avoided due to a low sensibility. P89 Novel swine inluenza A: most frequent ultrasonographic lung patterns L Tutino1, F Barbani1, G Cianchi2, S Batacchi2, L Perretta2, R Cammelli2, M Bonizzoli2, R Spina2, G Zagli2, A Peris2 1 Postgraduate School of Anesthesia and Intensive Care, Faculty of Medicine, Florence, Italy; 2Anaesthesia and Intensive Care Unit of Emergency Department, Careggi Teaching Hospital, Florence, Italy Critical Care 2010, 14(Suppl 1):P89 (doi: 10.1186/cc8321) Introduction Bedside lung ultrasound is able to identify with high sensibility and sensitivity most pulmonary pathological patterns and is widely adopted in critically ill patients’ daily management. It is a feasible Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 and reliable method for the identiication of the lung pathological patterns caused by H1N1 inluenza infection. Methods The study took place in the ICU of a regional referral center, with ECMO availability, for respiratory failure (Careggi Teaching Hospital, Florence, Italy). Eight patients admitted for H1N1-induced ARDS (September to October 2009) underwent daily LU examination. The examination was standardized with a procedure ad hoc in order to achieve complete and comparable reports for every patient. Patients were examined supine, taking lateral and anterior views and, if possible, on one side. Intercostal spaces were used as acoustic windows. Every single examination and its inding have been reported in our ICU database. Results Pleural thickness was present in 100% of cases, mostly related to little and multiple pleural consolidations. Anyway, pleural gliding was present most of the time (87.5%), even if with a visible decrease of its movement. This was replaced with the lung pulse only in the presence of important lung consolidation. Alveolar interstitial syndrome (AIS) was always present on the whole lung, ranging from moderate to severe (100%), with high positivity at the base, posteriorly (100%). White lung appeared in every patient, most at the lung base and in the middle ields, posteriorly. As far as consolidation is concerned, its presence was conirmed in 100% of the patients, associated with satellite multiple subpleural consolidations in 37.5% of patients. Basal lung was always involved (100%), followed by middle (50%) and apical ields(25%). Bronchogram was present in 100% of patients in bigger consolidations. Their aspect was aerial and only in one patient, with severe consolidations, turned into a luid one. Anechoic pleural efusions were found in 37.5% of patients. No cases of pneumothorax were detected. Conclusions In this group of patients, H1N1 infection shows diferent lung patterns altogether, where the most frequent seemed to be severe basal posterior AIS, multiple subpleural lung consolidations, and multiple parenchymal consolidation with bronchogram. The presence of spared areas did not seem to belong to H1N1 LU patterns. P90 Outcome and prognostic factors in patients with HIV-negative pneumocystis pneumonia requiring mechanical ventilation E Choi Asan Medical Center, Seoul, Republic of Korea Critical Care 2010, 14(Suppl 1):P90 (doi: 10.1186/cc8322) Introduction Pneumocystis pneumonia (PCP) in HIV-negative patients frequently presents as fulminant respiratory failure and is associated with a high mortality rate when the patient requires mechanical ventilation. The aims of this study were to evaluate the outcome and prognostic factors in the patients with HIV-negative PCP requiring mechanical ventilation (MV). Methods We retrospectively reviewed the medical records and collected the HIV-negative patients who were microbiologically conirmed as PCP and required MV in ICU over a 10-year period in a tertiary care teaching hospital. Results A total of 51 patients were identiied. Mean age was 55.4 ± 15.0 years. Mean APACHE II score at ICU admission was 25.7 ± 5.8. The 28-day mortality and in-hospital mortality were 45.8% and 66.7%, respectively. Between survivors and nonsurvivors, there were no signiicant diferences in baseline characteristics, APACHE II score, PaO2/FiO2 ratio, and absolute neutrophil counts on ICU admission day. Also the mortality was not diferent in relation to the presence of barotrauma, application of noninvasive ventilation, timing of susceptible antibiotic administration, changing or not to salvage regimens, presence of cytomegalovirus coinfection and even the microbiologic persistency in follow-up specimens. Based on the types and intensity of previous immunosuppressive therapy, we classiied patients into three subgroups: patients receiving low-dose steroid maintenance ± other immunosuppressive agents (LS), which represent previously stable organ transplants; another group consisting of patients receiving recent intensive chemotherapy (CTx); and the other group refers to patients receiving high dose (deined as >2 weeks at least 1 mg/kg dose) steroid therapy ± other immunosuppressive agents (HS). Signiicant diferences of outcome were observed among the three diferent groups (28-day mortality: LS = 22.2%, CTx = 29.4%, HS = 71.4%, P = 0.01; 60-day mortality: LS = 33.3%, CTx = 64.7%, HS = 81.0%, P = 0.04). Conclusions Our data showed that the mortality of fulminant HIVnegative PCP requiring MV was signiicantly diferent according to the S32 types and intensity of previous immunosuppressive treatment despite similar clinical features on ICU admission. P91 Acute respiratory failure from pandemic inluenza A (H1N1) in an intensive care unit in southern Brazil S Beduschi Filho, D Siqueira, SC Carvalho Flores, I Yoshiko Masukawa, L Kretzer, AC Burigo Grumann, I Silva Maia, M Pimentel Pincelli Hospital Nereu Ramos, Florianópolis, Brazil Critical Care 2010, 14(Suppl 1):P91 (doi: 10.1186/cc8323) Introduction In the winter of 2009 the inluenza A (H1N1) pandemic reached Brazil, afecting severely its southern states. A total 68,806 cases of suspected pandemic inluenza A infection had been reported in Brazil and 91% of the specimens tested were positive. Incidence of pandemic inluenza A in southern Brazil was 137/100,000. In the southern Brazilian state of Santa Catarina, Nereu Ramos Hospital is the referral center for the treatment of infectious diseases, and it provided eight intensive care beds for the management of acute respiratory failure from suspected cases of inluenza A during the 2009 pandemic. Methods We collected retrospective data on the epidemiological features, clinical course and ventilatory characteristics of patients with laboratoryconirmed inluenza A (H1N1) infection who were admitted to our ICU during the winter of 2009. Results Thirty-four adult patients were admitted to our ICU with acute respiratory failure and suspected pandemic inluenza A infection. Of these, 14 cases tested positive for inluenza A (H1N1). The majority of the patients were male (61.5%) with median age of 27.5 years and interquartile range (IR) of 26.5 to 48.5. The APACHE II median was 14.5 (IR 10.0 to 18.25) with median predicted mortality of 20.0 (IR 10.73 to 27.7). Risk factors were: obesity (23.1%), obstructive respiratory diseases (15.4%); pregnancy, immunosuppressive and neuromuscular disorders were present in one patient each. All 14 patients presented severe respiratory failure, with a median lowest PaO2/IOF of 113.3 (IR 83.53 to 159.55) and 92.3% of them requiring mechanical ventilation. The patients in mechanical ventilation were all ventilated in pressured-controlled mode, demanded high PEEP levels (mean of 18.5 ± 5.16 cmH2O), presented high peak inspiratory pressure (mean of 37.83 ± 7.35 cmH2O) and required elevated IOF (81.15 ± 20.83%). A total of 57.1% of the patients were submitted to lung recruitment, while the prone position was used in 42.8% of them. The median ICU stay was 13.0 days (IR 4.75 to 23.50) and the median hospital stay was 16.5 days (IR 9.75 to 25.0). The ventilatory-associated pneumonia (VAP) rate was unusually high (69.2%) as well as the mortality rate during the intensive care stay (38.5%). Conclusions Patients admitted to our ICU with conirmed pandemic inluenza A infection presented severe acute respiratory failure and an unusually high incidence of VAP and mortality rates. Reference 1. Perez-Padilla R, et al.: Pneumonia and respiratory failure from swine-origin inluenza A (H1N1) in Mexico. N Engl J Med 2009, 361:680-689. P92 Extracorporeal membrane oxygenation for inluenza A (H1N1): experience in a regional referral center A Pasquini1, S Di Valvasone2, S Biondi2, S Batacchi1, G Cianchi1, M Ciapetti1, M Bonizzoli1, R Spina1, L Turrisi1, E Mascitelli3, M Bonacchi3, G Zagli1, GF Gensini3, A Peris1 1 Careggi Teaching Hospital, Florence, Italy; 2Postgraduate School of Anesthesia and Intensive Care, Florence, Italy; 3University of Florence, Italy Critical Care 2010, 14(Suppl 1):P92 (doi: 10.1186/cc8324) Introduction The novel inluenza A H1N1 virus can cause, in a restricted subgroup of infected patients, an acute respiratory failure not responding to conventional treatment. In selected cases, extracorporeal membrane oxygenation (ECMO) has been applied with a 21% mortality rate. Here we report the experience of the ICU of a regional referral center for ECMO (Careggi Teaching Hospital, Florence, Italy). Methods An Emergency Medical Service has been established for the novel pandemic inluenza to guarantee the possibility of ECMO initiation in the peripheral hospitals by our ECMO Team and the subsequent transport Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 on extracorporeal circulation to our referral center. The ECMO Team is composed of an intensivist, a cardiac surgeon, a cardiologist, a perfusionist and a nurse. All of the diferent igures were properly trained and formed on ECMO treatment. According to our internal protocol, eligible patients for ECMO treatment are aged 15 to 70 years old with acute respiratory failure with one of the following conditions: a ratio PaO2/FiO2 <60 or pH <7.20 under protective ventilation conditions. ECMO insertion was achieved percutaneously and a high-low approach (5 to 6 l/minute) was initially established according to patient need. ECMO device is a Rotalow Maquet Centrifugal Pump with a Quadrox-D oxygenator (Maquet, Rastatt, Germany) and biocoated circuits. H1N1 infection was monitored by RTPCR examination on pharyngeal swab and bronchial aspirate. Antiviral therapy was conducted by oral administration of oseltamivir (75 mg twice daily), and inhaled zanamivir (10 mg twice daily). Results From October 2009 to November 2009, six patients with inluenza A (H1N1) have been treated with ECMO support. Three patients were cannulated in the district hospital and transported safety to our ICU by our ECMO Team. Median SAPS II at admission, median age and sex were as listed as follows: 46, 35 years old and ive males/one female. All patients had an acute respiratory failure accompanied by a multiorgan dysfunction. ECMO was established and maintained for 200 hours. All patients were successfully weaned from ECMO support, extubated and discharged from our ICU. No major procedure-related complications were observed. Conclusions Well-timed ECMO use in cases of inluenza A H1N1 acute respiratory failure could improve overall the survival rate. P93 Budd–Chiari syndrome complicated by abdominal compartment syndrome: evidence of central hypovolaemia? D Joshi, S Saha, W Bernal, J Wendon, G Auzinger King’s College Hospital, London, UK Critical Care 2010, 14(Suppl 1):P93 (doi: 10.1186/cc8325) Introduction Budd–Chiari syndrome (BCS) is characterised by hepatic venous outlow obstruction (HVOO) leading to post-sinusoidal portal hypertension, congestion of the liver with caudate lobe hypertrophy. In addition to intra-abdominal hypertension (IAH), caused by severe ascites, HVOO may aggravate the cardiovascular disturbances seen in patients with decompensated disease. The aim was to study the haemodynamic response to abdominal decompression in BCS compared with patients with decompensated cirrhosis. Methods Ten patients with BCS admitted to the Liver ICU, King’s College Hospital were studied. Transpulmonary thermodilution cardiac output monitoring and calculation of volumetric indices of preload was performed with the PiCCO system. Haemodynamic variables and IAP were analysed pre and post intervention. The control group comprised of cirrhotic patients with IAH requiring abdominal paracentesis (PC). Results Ten patients with BCS were studied, median age 39 years (range (R) 20 to 52); eight had liver transplantation and two had a surgical shunt procedure. Eight patients (PC), median age 59 (33 to 65), underwent abdominal paracentesis for tense ascites. IAP was raised in both groups pre intervention (23, R 17 to 40, BCS vs 26, R 20 to 40, PC). ITBVI remained low in the BCS group (632, R 453 to 924) pre intervention despite aggressive volume resuscitation (median positive FB10L, R 0.5 to 39). Post intervention, a reduction in IAP was seen in both groups (BC P <0.001, PC P <0.0001). ITBVI increased (633, R 453 to 924 vs 736, R 512 to 1,110, P = 0.001) in BCS patients. No change in ITBVI was noted (pre 870, R 598 to 1,619 vs post 1,036, R 763 to 1,762) in the CP group despite albumin replacement. An increase in CI and SVI was noted in both groups: BCS (CI P = 0.003, SVI P = 0.007), CP (CI P = 0.005, SVI P = 0.02). There was an inverse relationship between IAP, CI (P = 0.003), SVI (P = 0.004) and ITBVI (P = 0.01) in BCS patients. In the CP group, IAP did not correlate with ITBVI. Conclusions Compared with cirrhotic patients with ascites, patients with BCS and IAH have evidence of central hypovolaemia. We postulate that in addition to raised IAP, hepatic venous obstruction and caudate lobe hypertrophy limit venous return in patients with BCS. Reduction in IAP restores preload with improvement in cardiac output. References 1. 2. Cheatham et al.: Intensive Care Med 2007, 33:951-962. Malbrain et al.: Intensive Care Med 2006, 32:1722-1732. S33 P94 Adenosine signalling has a protective role in intestinal ischemia and reperfusion injury K Zimmermann1, T Krieg2, M Soltow1, D Pavlovic1, J Zhou3, S Whynot3, O Hung3, M Murphy3, C Lehmann3 1 Ernst Moritz Arndt University Greifswald, Germany; 2Department of Cardiology, Cambridge, UK; 3Dalhousie University, Halifax, Canada Critical Care 2010, 14(Suppl 1):P94 (doi: 10.1186/cc8326) Introduction Gut ischemia and reperfusion (IR), for example in small bowel transplantation or following resuscitation, may result in severe impairment of the intestinal microcirculation. Potential sequelae are mucosal damage, loss of barrier function, bacterial translocation, systemic inlammation, multiple organ failure and death. We hypothesized that extracellular adenosine signalling has a protective role in intestinal IR injury. Using intravital microscopy we investigated the efects of the adenosine receptor agonist NECA (5΄-N-ethyl carboxamide adenosine) on leukocyte–endothelial interactions and capillary perfusion in the intestinal microcirculation following intestinal IR. Methods Six groups of animals (n = 7 per group) were studied: control (CON), NECA, IR (30 minutes of intestinal ischemia, 2 hours of reperfusion), IR + NECA, IR + NECA + MRS1754 (adenosine A2B receptor antagonist), IR + NECA + DPCPX (adenosine A1 receptor antagonist). All substances were administered immediately after declamping of the superior mesenteric artery. Intravital microscopy was performed after 2 hours of reperfusion. Leukocyte adhesion (rolling/irm adherence) and functional capillary density (FCD) were measured oline by blinded investigators. Results Following IR we observed a signiicant increase of leukocyte adherence in the intestinal submucosal venules (for example, V1 venules: CON 20.1 ± 5.8 n/mm2, IR 237.8 ± 24.2 n/mm2, P <0.05). Capillary perfusion of the muscular layers of the intestinal wall was reduced (for example, longitudinal muscular layer: CON 112.3 ± 5.3 cm/cm2, IR 92.4 ± 8.4 cm/ cm2). NECA administration reduced signiicantly leukocyte adherence (V1 venules: 67.8 ± 6.8 n/mm2, P <0.05) and improved capillary perfusion (longitudinal muscular layer: 113.9 ± 8.3 cm/cm2). Administration of the adenosine A2B receptor antagonist completely reversed the NECA efects (for example, leukocyte adherence V1 venules: 228.8 ± 33.2 n/mm2), whereas A1 receptor inhibition only partially abolished the action of NECA (for example, leukocyte adherence V1 venules 124.5 ± 14.5 n/mm2). Conclusions The data support the hypothesis, that adenosine signalling is involved in intestinal IR injury. The adenosine A2B receptors are more important than adenosine A1 receptors since inhibition of A2B receptor by MRS1754 completely reversed the efect of the adenosine receptor agonist NECA. References 1. 2. 3. Förster et al.: Basic Res Cardiol 2006, 101:319-326. Solenkova et al.: Am J Physiol 2005, 290:H441-449. Hart et al.: J Immunol 2009, 182:3965-3968. P95 Hemodynamic states during the course of norepinephrine weaning E Kipnis, H Tytgat, N Bruneau, B Leroy, G Lebufe, B Tavernier, B Vallet Centre Hospitalier Régional Universitaire de Lille, France Critical Care 2010, 14(Suppl 1):P95 (doi: 10.1186/cc8327) Introduction Norepinephrine is a standard of care in the hemodynamic management of septic shock concomitantly to luid administration. However, no guidelines exist concerning norepinephrine weaning. Furthermore, norepinephrine may rapidly restore macrocirculatory hemodynamics through stressed volume without treating the underlying volume deicit, especially in the absence of optimal volume expansion. Norepinephrine weaning may reveal latent/persisting need for volume expansion in apparently stable patients. Methods Observational study of norepinephrine weaning in seven resuscitated SICU septic shock patients. Weaning was performed in 0.1 mg/ hour decrements every 5 to 15 minutes until hemodynamic instability, deined as a mean arterial pressure (MAP) ≤70 mmHg, interrupted the process, at which point pulse pressure variation (PPV) was measured and transthoracic echocardiography (TTE) performed as per standard procedures. Upon instability with PPV ≥13%, 250 ml luid challenge was performed and the MAP increase allowed pursuit of weaning, whereas Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S34 instability with PPV <13% halted weaning. Nonparametric correlations were sought between norepinephrine decrements and variations over weaning (and luid challenge) in PPV, arterial compliance, and indexed systolic ejection volume (iSEV). Global resuscitation endpoints (serum lactate, ScvO2) were compared before and after the entire weaning process. Results Two behaviors were observed. First, norepinephrine weaning unmasked latent preload dependency in steps characterized by marked PPV increase (16.5%, 8 to 36), correlated to norepinephrine decrements (ρ = 0.971; r2 = 0.745; P = 0.005) resulting in PPV ≥13% and luid challenge increasing the MAP and allowing pursuit of weaning. Second, weaning revealed norepinephrine dependency in steps halted by instability and characterized by slight PPV increases (3.9%, 0.3 to 8.4), resulting in PPV <10%, and a decrease in iSEV that was correlated to norepinephrine decrements (ρ = 0.943; r2 = 0.830; P = 0.001). Globally, weaning decreased serum lactate to under 2 mmol/l with ScvO2 maintained above 70%. Conclusions Hemodynamic stability through norepinephrine use in septic shock might be at the cost of occulting residual luid requirements which can be revealed during norepinephrine weaning. P96 Threshold levels of extreme body surface area that may cause a misrepresentation of cardiac performance WT McGee1, BH Nathanson2 1 Baystate Medical Center, Springield, MA, USA; 2OptiStatim, LLC, Longmeadow, MA, USA Critical Care 2010, 14(Suppl 1):P96 (doi: 10.1186/cc8328) Introduction Stroke volume (SV) and cardiac output (CO) are standardized into the stroke index (SI) and cardiac index (CI) by dividing by the patient’s body surface area (BSA). Commonly used algorithms in hemodynamic management suggest diverse therapeutic interventions based on low, high, or normal SI or CI. Morbid obesity is increasingly common. When morbidly obese patients have their SV or CO indexed, high absolute values become low SI and CI, and may be misleadingly low. This would then cause therapeutic interventions opposite to their needs. Methods BSA was derived using the Mosteller formula on the metric equivalent of simulated patients ranging from 5 ft to 7 ft and 100 lbs to 700 lbs. A priori, we deined normal CO = 4 to 8, normal CI = 2.5 to 5.0, normal SV = 60 to 100 ml/beat, and normal SI = 33 to 47. Algebraic analysis was used to determine BSA levels that would classify an SV or CO as abnormal. Results Critical BSA thresholds (T) are presented in Table 1. For example, at SV = 100, a BSA higher than 3.03 (to the second decimal place) would classify the patient as having a low SI. Table 1 (abstract P96) SV T CO T 90 2.72 7 2.80 100 3.03 8 3.20 110 3.33 9 3.60 120 3.64 10 4.00 130 3.94 11 4.40 Conclusions Patients with extreme BSAs are increasingly encountered in the ICU, especially larger BSAs related to obesity. We provide threshold values where extreme BSAs will classify high SV or CO values as low indexed values. The ranges considered normal for SI and CI may be inappropriate for patients with extreme BSAs, particularly in the obese. We caution against relying solely on the SI and CI to assess hemodynamic performance. Instead, the SV and CO along with other physiological parameters should also be considered before making therapeutic decisions. P97 Cardiac output measurement is feasible in the presence of left-to-right shunt with ultrasound dilution method: a validation study in lambs S Vrancken, W De Boode, J Hopman, S Singh, K Liem Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands Critical Care 2010, 14(Suppl 1):P97 (doi: 10.1186/cc8329) Introduction It remains a great challenge to measure systemic blood low in critically ill newborns, especially during the transitional period with intracardiac and extracardiac shunts. Due to technical restraints, size limitations, the necessity for a relatively large amount of blood withdrawn and possible indicator toxicity, many methods of cardiac output monitoring are not feasible, hence cardiac output is generally estimated from indirect parameters of systemic blood low. In a former study we assessed the agreement for cardiac output using the ultrasound dilution method (UDCO) and ultrasound transit time-based measurement of main pulmonary blood low in a juvenile piglet model without shunts [1]. In the present study we analyzed the inluence of a left-to-right shunt on the agreement between UDCO and ultrasonic transit time pulmonary blood low in a juvenile lamb model. Methods In this prospective, experimental animal study, which was approved by the Ethical Committee on Animal Research of the Radboud University Nijmegen, we placed a Gore-Tex® shunt between the left pulmonary artery and the descending aorta in eight randombred newborn lambs (3.5 to 8.3 kg). This aortopulmonary shunt was intermittently opened and closed while cardiac output was manipulated by creating hemorrhagic hypotension. Ultrasound dilution cardiac output (Q-UDCO) – using repeated injection of 1.0 ml/kg isotonic saline at body temperature – was compared with pulmonary blood low (Q-MPA) invasively measured by a perivascular low probe around the main pulmonary artery. Results A total of 220 measurements were performed. Bias, deined as Q-UDCO minus Q-MPA, was calculated for each measurement. With an open shunt there was a signiicant left-to-right shunt (mean Qp-/Qs- ratio 1.8; range 1.6 to 2.6). Mean bias (SD) was 6.80 (18.0) ml/kg/minute with a closed shunt and 11.1 (19.8) ml/kg/minute with an open shunt. Limits of agreement (±1.96 SD) were ±35.2 ml/kg/minute and ±38.8 ml/kg/minute, respectively. Percentage error was 22.0% and 24.2% for measurements with a closed and open shunt, respectively. Conclusions Cardiac output measurement with the UDCO method is reliable and easily applicable in ventilated juvenile lambs, even in the presence of a signiicant left-to-right shunt. Reference 1. de Boode WP, et al.: Pediatr Crit Care Med 2009, 9. [Epub ahead of print] P98 The PAPIKAS trial: a comparative clinical trial of pulmonary catheter versus the PiCCO device during therapy of patients with acute heart failure and cardiogenic shock T Schwab, B Schmid, S Richter, C Bode, HJ Busch University Hospital, Freiburg, Germany Critical Care 2010, 14(Suppl 1):P98 (doi: 10.1186/cc8330) Introduction Haemodynamic measurement plays an important role in the treatment of patients with acute heart failure and cardiogenic shock (CS). The pulmonary catheter (PAC) is a common device for enhanced haemodynamic measurement. The aim of this study was to evaluate the comparability of the PiCCO device with the PAC during the treatment of patients with CS; for example, the use of intra-aortic counterpulsion (intraaortic balloon pumping (IABP)), and therapeutic hypothermia after cardiac arrest. Methods Seventy-seven measurements were taken in 11 critically ill patients during the therapy of cardiogenic shock. The cardiac index (CI), stroke volume (SVI), and systemic vascular resistance (SVRI) were measured by pulmonary catheter and PiCCO device, as well as the pulmonary aortic occlusion pressure (PAWP) with a pulmonary catheter and the global end-diastolic volume (GEDI) with the PiCCO device, and registered in a commercially available computer system. Results A good correlation between the two techniques in all data, as well as during the use of IABP or during hypothermia was shown. The Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S35 mean bias between CIpa and CIart was 0.042. The calculated mean error was 24.89%, 26.17% and 19.08%, respectively. There was also a good convergence between the measurements of vascular resistance in overall data and during IABP. Signiicant correlations were found for SVIpa, SVIpi, SVRIpa, SVRIpi to CIpa. For GEDI there was a signiicant correlation with CIpa for data collected during cooling. No signiicant correlation between PAWP und CIpa was found. Conclusions The data show interchangeability for the two methods using intermitting measurements during therapy of cardiogenic shock even during intra-aortic counterpulsation and therapeutic hypothermia. The cardiac output seems to be related to the GEDI as a preload parameter; no relationship between PAOP and CI can be shown. The usability of the less invasive PiCCO device for the enhanced hemodynamic measurement in patients with acute heart failure and cardiogenic shock is ensured. P99 Bioreactance versus PICCOTD/PC in critically ill septic shock patients G Monti1, G Pizzilli1, M Cecconi2, A Rhodes2, S Vesconi1, P Brioschi1, M Pulici1, G Casella1 1 Niguarda Hospital, Milan, Italy; 2St George’s Hospital, London, UK Critical Care 2010, 14(Suppl 1):P99 (doi: 10.1186/cc8331) Introduction We designed this study to compare the performance in cardiac output (CO) monitoring capabilities of two devices in refractory septic shock patients (RSS Pts): non-invasive transthoracic bioreactance (NICOM) and pulse contour analysis (PICCO PC) coupled to transpulmonary thermodilution (PICCOTD). Methods We included RSS Pts in vasopressor/inotrope need monitored with both devices. Triplicate measurements of CO by PICCOTD were used to measure CO at baseline and to calibrate PulseCO. The CO values recorded simultaneously minute-by-minute by the two systems were compared at baseline (nonperturbated system), in response to a passive leg-raising maneuver (PLR = leg elevation to 45° for 2 minutes starting from a supine position) and PEEP test (10 and 15 cmH2O for 10 minutes each) (perturbated system). We used PICCOTD/PC as the reference technology evaluating the accuracy and estimating the precision of both devices. Results Continuous CO recording with both devices was performed on 12 consecutive RSS Pts (Nep + Epi = 0.66 ± 0.15 μg/kg/minute, all ventilated with TV <8 ml/kg). At baseline (nonperturbated system), correlation analysis of NICOM vs PiCCOTD CO showed r2 of 0.78 (P <0.001). Bland– Altman analysis evidenced a mean bias of 0.08 l/min (LOA –1.31 to 1.49). The mean CO was 6.01 ± 1.48 l/min. In a perturbated system the bias of NICOM vs PICCO PC was respectively–0.05 l/min (LOA –1.52 to 1.42) and 0.3 l/min (LOA –2 to 2.6) during PLR and PEEP test. The percentage error was <30% in 92% of patients at baseline (nonperturbated system), in 92% of patients during PLR and in 74% during PEEP test. In a nonperturbated system the CO precision (calculated as 2 SD/mean over 10 consecutive measurements) was 6.5 ± 6% and 6.7 ± 9% for NICOM and PiCCOTD, respectively (NS). Precision for NICOM and PICCOPC was respectively 6.8 ± 13% and 4.7 ± 10% during PLR and 7 ± 15% and 7.6 ± 15% during PEEP test. Conclusions Although limited to a small number of patients, NICOM and PICCO PC, calibrated by TD, seem to have comparable accuracy and precision in CO monitoring in RSS Pts even in a perturbated system. References 1. 2. Squara P: Intensive Care Med 2007, 33:1191-1194. Squara P: Crit Care 2009, 13:R125. P100 NICOM vs LiDCO™plus during changes in cardiac output in critically ill patients M Cecconi1, G Monti2, S Vesconi2, M Hamilton1, M Grounds1, A Rhodes1 1 St George ‘s Hospital, London, UK; 2Niguarda Hospital, Milan, Italy Critical Care 2010, 14(Suppl 1):P100 (doi: 10.1186/cc8332) Introduction NICOM (Cheetah) is a new non-invasive cardiac output (CO) monitor based on bioreactance. We tested the agreement of NICOM vs LiDCO™plus in terms of absolute CO values and of the ability to track changes after therapeutic intervention in critically ill patients. Figure 1 (abstract P100). ROC analysis for NICOM CO in R and NR. Methods Patients requiring haemodynamic monitoring were monitored with LiDCO™plus and NICOM. Three measurements of CO by LiDCO were used to measure CO at baseline and to calibrate PulseCO. After luid challenges (FC = 250 ml colloid/5 minutes) or inotropic therapy alterations, the change in stroke volume (SV) for PulseCO and NICOM CO was recorded. Patients able to increase SV ≥10% as measured by PulseCO were considered responders (R). Bland–Altman analysis was performed for NICOM vs LiDCO CO at baseline. The coeicient of variation (CV) and percentage error (PE) were calculated. ΔSV of NICOM vs PulseCO was analysed with correlation analysis. In patients receiving FC, a ROC analysis was performed to detect the sensitivity and speciicity of NICOM to track ΔSV as measured by PulseCO CO. Results Baseline haemodynamics in 30 patients enrolled: BA analysis for NICOM vs LiDCO CO showed a mean bias of –0.18 l/minute (LOA –2.5 to 2.16). Mean CO was 5.8 l/minute, PE was 41%. Mean LiDCO CO CV was 6.8%. A total of 81 pairs of data were collected after FC or inotrope dose change. Correlation analysis showed r2 of 0.55 (P <0.0001) for changes post FC and r2 of 0.54 (P <0.006) post inotrope dose changes. ROC analysis for NICOM CO in R and NR after a FC showed an area under the curve (AUC) of 0.8 (P <0.0001; Figure 1). An increase in NICOM SV >8% showed a sensitivity of 76% and a speciicity of 75% to predict PulseCO changes >10%. Conclusions NICOM demonstrated a moderate agreement with LiDCO but showed excellent agreement with PulseCO in tracking CO changes following therapeutic interventions. P101 Efect of cardiac arrhythmias on PulseCO calibration and performance M Jonas1, E Mills2, C Wolf2, T O’Brien2 1 Southampton University Hospital, Southampton, UK; 2LiDCO Ltd, London, UK Critical Care 2010, 14(Suppl 1):P101 (doi: 10.1186/cc8333) Introduction Arrhythmias are common among high-risk surgical and ICU patients. The PulseCO pressure waveform algorithm is used for both LiDCO™plus and LiDCOrapid hemodynamic monitors, which are frequently used to estimate cardiac output (CO) in critically ill patients. Cardiac arrythmias could increase the variation of both the lithium dilution (LiDCO) and/or the PulseCO measurement. At set-up the algorithm is calibrated by comparing the PulseCO CO estimate, averaged over 30 seconds, with a known CO (normally LiDCO) to generate a calibration factor (CF) [1]. This study was designed to explore the efect of arrythmias on the accuracy of CF generation in the PulseCO monitor. Methods LiDCO™plus hemodynamic data iles were obtained retrospectively from a university hospital medical/surgical ICU. Files were separated into those records with and without arrhythmia – deined as heart rate variation >5% during at least one additional CF determination after monitor set-up. Previous studies have established the coeicient of variation (CV) of a single LiDCO determination at 8% [2] and the PulseCO measurement at 2.4% [3]. A combined CV, relecting the efect of calibration, is estimated at 8.5%, resulting in an expected precision for the CF of 17%. Data were analysed for variation in CF against HRV using linear regression and the Student’s t test. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Results Twenty-eight records were collected and analysed. Twenty-one records contained 32 post set-up calibration events. Of these 17 occurred with HRV ≤5% (median = 1%, range: 0 to 5%) and 15 occurred while HRV >5% (median: 19%, range: 7 to 26%). The average variation in CF during HRV was 5.4 ± 4.0% and for high HRV was 8.9 ± 8.1% of the initial value. The t test indicated no diference in the mean variation of CF (P = 0.162) or median. There was no correlation between HRV and CF variation (r2 = 0.002). Ninety-one per cent (29/32) of the observed CF variation were less than 17% of the initial CF value. Conclusions CF determinations are not signiicantly afected by HRV. PulseCO estimates CO acceptably in the presence of arrhythmias. Interpretation of the data is enhanced by using at least 30 second averaging. References 1. 2. 3. Rhodes A, et al.: Functional Hemodynamic Monitoring Update in Intensive Care and Emergency Medicine, volume 42, 2005:183-192. Cecconi M, et al.: Intensive Care Med 2009, 35:498-504. Kemps H, et al.: J Appl Physiol 2008, 105:1822-1829. P102 PulseCO consistency: variation in calibration factor over 24 and 48 hours E Mills1, M Jonas2, C Wolf1, T O’Brien1 1 LiDCO Ltd, London, UK; 2Southampton University Hospital, Southampton, UK Critical Care 2010, 14(Suppl 1):P102 (doi: 10.1186/cc8334) Introduction The PulseCO pressure waveform algorithm is used for both LiDCO™plus and LiDCOrapid hemodynamic monitors to estimate cardiac output (CO). The accuracy of this CO estimate is achieved by comparing (calibrating) the PulseCO with a known CO, for example from the lithium dilution or LiDCO which scales the software algorithm and reduces the bias to the actual CO [1]. This calibration/scaling factor (CF) is patient speciic and should not signiicantly change over a period of a few days as it relects the patient’s aortic capacitance. Methods LiDCO™plus hemodynamic data iles were obtained retrospectively from a university hospital medical/surgical ICU. Files were screened to obtain records with at least 24 hours of continuous hemodynamic data and at least one calibration at 24 hours following the initial set-up calibration. Data were analysed for change in CF from initial calibration over 24 and up to 48 hours. Relative change in CF was analyzed for correlation with changes in SVR and CO. Results Twenty-one records contained at least 24 hours of data with a calibration at 24 hours. Eleven contained at least 48 hours of data and a further calibration at 48 hours. The 32 calibrations were reviewed for consistency of PulseCO and LiDCO results. The average variation in CF over 24 hours (7.4 ± 6.9% (mean ± SD)) and 48 hours (6.5 ± 6.2%) were similar (P = 0.362). Average changes in SVR were 24.7 ± 27.4% (range: 0 to 130%); average CO changed by 21.4 ± 17% (range: 0 to 57%) over 24 hours. There was no correlation between the variation in CF and changes in either CO or SVR. Conclusions It is known that the estimated coeicient of variation of a single measurement of LiDCO is 8% [2] and PulseCO is 2.4% [3]. An orthogonally combined CV, relecting the efects on CF, is estimated at 8.5%, or precision of 17%. Ninety-one per cent (29/32 ) of the observed CF changes were less than 17% of the initial CF. The PulseCO CF remains constant despite changes in SVR of up to 130% and CO of up to 57% over periods of 24 to 48 hours. References 1. 2. 3. Rhodes A, et al.: Functional Hemodynamic Monitoring Update in Intensive Care and Emergency Medicine, volume 42, 2005:183-192. Cecconi M, et al.: Intensive Care Med 2009, 35:498-504. Kemps H, et al.: J Appl Physiol 2008, 105:1822-1829. P103 Performance of cardiac output measurement derived from arterial pressure waveform analysis in patients undergoing triple-H-therapy of cerebral vasospasms after subarachnoidal hemorrhage SM Metzelder, R Kopp, M Fries, M Reinges, S Reich, R Rossaint, G Marx, S Rex RWTH Aachen, Germany Critical Care 2010, 14(Suppl 1):P103 (doi: 10.1186/cc8335) Introduction The validity of an arterial waveform-based device for measuring cardiac output (CO) without the need for invasive calibration S36 (FloTrac/Vigileo) in patients needing large doses of vasoactive medication has not yet been thoroughly studied. We performed the present study to assess the validity of both the second-generation and the thirdgeneration software compared with transpulmonary thermodilution CO measurement using the PiCCO technology in patients undergoing triple-H-therapy (hypertonia, hypervolemia, hemodilution) of cerebral vasospasms after subarachnoidal hemorrhage. Methods Twenty-three patients (18 females and ive males) were included in this study. All of them were sufering from a subarachnoidal hemorrhage (Hunt&Hess grade I to V) due to rupture of a cerebral aneurysm. Triple-H-therapy was initiated for the treatment of cerebral vasospasm. Simultaneous CO measurements by bolus thermodilution and the FloTrac/Vigileo device were obtained at baseline as well as 2 hours, 6 hours, 12 hours, 24 hours, 48 hours and 72 hours after inclusion. A percentage error of 30% or less was established as the criterion for method interchangeability. Results Patients received vasoactive support with 0.53 ± 0.46 μg/kg/ minute norepinephrine, resulting in a mean arterial pressure of 104 ± 13.6 mmHg and a systemic vascular resistance index of 1,741.17 ± 432.50 dyn·s/cm5/m2. One hundred and ifty-one CO-data pairs were analyzed. Transpulmonary thermodilution CO ranged from 5.18 to 14.28 l/minute (mean 8.61 ± 1.93 l/minute) and FloTrac/Vigileo CO ranged from 4.1 to 13.7 l/minute (mean 7.62 ± 1.79 l/minute). Bias and precision (1.96SD of the bias) were 0.99 l/minute and 2.46 l/minute, resulting in an overall percentage error of 28.55%. Subgroup analysis revealed a percentage error of 29.53% for 67 data pairs measured using the second-generation FloTrac software and 26.44% for 84 data pairs analyzed by the third-generation software. Conclusions In patients undergoing triple-H-therapy and needing extensive vasoactive support, CO values obtained by arterial waveform analysis showed good agreement with intermittent transpulmonary thermodilution CO measurements, which was improved by the introduction of a new software generation. References 1. Mayer J, Boldt J, Wolf MW, Lang J, Suttner S: Cardiac output derived from arterial pressure waveform analysis in patients undergoing cardiac surgery: validity of a second generation device. Anesth Analg 2008, 106:867-872, table. P104 Inluence of systemic vascular resistance on cardiac output measured by new non-invasive cardiac output monitor K Yamashita, T Yamatabe, H Abe, M Yokoyama Kochi Medical School, Kochi, Japan Critical Care 2010, 14(Suppl 1):P104 (doi: 10.1186/cc8336) Introduction Early manipulation of hemodynamic variables has been reported to be able to improve the outcome of patients. Cardiac output (CO) was an important parameter to understand the status of hemodynamics. Recently, the pulse-contour method is widely used to estimate CO, because it is non-invasive and easy to use. However, the change in the systemic vascular resistance (SVR) afects CO measured by the pulse-contour method. In this study, we evaluated the new noninvasive cardiac output monitor [1] based on pulse pressure analysis combined with pulse-wave transition time (estimated continuous CO; esCCO) compared with the conventional thermodilution method under a clinical setting. Methods Twenty-ive surgical patients who underwent cardiac or vascular surgery (ASA physical status 2) were enrolled in this study. After anesthesia induction, radial arterial catheter and pulmonary artery catheter were inserted. Intermittent cardiac output (ICO) was measured by thermodilution method in triplicate and averaged (<5°C saline 10 ml in each measurement) using Vigilance (Edwards Life Science, Irvine, CA, USA). Echocardiogram, pulse oximetry and arterial blood pressure were also monitored and connected to personal computer to calculate esCCO. Bland and Altman plots were used to evaluate the percentage diference in CO in relation to SVR. Results One hundred matched sets of data were obtained. The limit of agreement (bias ± 2SD of bias) was –2.9 ± 31.9%. Only ive measurements were exceeded – 30% against ICO. Each SVR was 1,159, 1,376, 1,418, 2,567, 3,150 dyn·s/m5. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S37 Conclusions The diference in most CO was within ±30% against the reference values, although CO was underestimated by esCCO under the relative high SVR. COs estimated by esCCO were acceptable under the clinical setting. Therefore, we concluded that esCCO was a useful algorithm to estimate CO. References Conclusions The performance of pulse contour methods has signiicantly increased in the past few years, which makes comparisons with older publications invalid. The auto-calibrated FloTrac/Vigileo system can replace the initially PAC-calibrated LiDCO and PiCCO system. 1. P106 Continuous cardiac output measurement: efect of time R De Wilde, B Geerts, P Van den Berg, J Jansen Leiden University Medical Center, Leiden, the Netherlands Critical Care 2010, 14(Suppl 1):P106 (doi: 10.1186/cc8338) J Clin Monit Comput 2004, 19:313-330. P105 Comparison of cardiac output values; pulse contour methods against thermodilution technique R De Wilde, B Geerts, P Van den Berg, J Jansen Leiden University Medical Center, Leiden, the Netherlands Critical Care 2010, 14(Suppl 1):P105 (doi: 10.1186/cc8337) Introduction We evaluated the performance of the FloTrac/Vigileo system (FCO) and simultaneously obtained cardiac output (CO) values with the PiCCOplus (PCO), LiDCO™plus (LCO), Vigilance continuous pulmonary artery thermodilution (CCO) against the intermittent pulmonary artery thermodilution technique (ICO). Methods Data were collected during standard postoperative care in 28 cardiac surgery patients. The cardiac output data were collected at 1 hour (T1), 2 hours (T2), 4 hours (T3), 8 hours (T4), 12 hours (T5), 24 hours (T6), 36 hours (T7), and 48 hours (T8) after ICU admission. The number of observations per patient varied between four and eight. Data were analyzed with Bland–Altman statistics. Results Reference cardiac output (ICO) ranged from 2.90 to 8.70 l/minute, mean value of 5.12 (SD = 1.02) l/minute. Agreement between methods against the reference method are also expressed in a percentage (LOA%); that is, at low CO a small error and at high CO a higher error is observed. The distribution of errors is diferent among the methods (Figure 1). This is conirmed by Levine’s statistics, which showed signiicant (F value = 20.5, P <0.001) unequal homogeneity of the variances of the four methods. For CCO bias and limits of agreement are 0.31 and –0.99 to 1.61. Bias and limits of agreement of FCO, LCO and PCO are 0.59, –1.37 to 2.55; –0.05, –1.99 to 1.89 and –0.16, –2.60 to 2.28 l/minute, respectively. Figure 1 (abstract P105). Introduction Calibration turns pulse contour methods of cardiac output measurement from continuous to intermittent. We evaluated the necessity to recalibrate pulse contour cardiac output methods; LiDCO™plus (LCO), FloTrac/Vigileo (FCO), PiCCO (PCO) and continuous CO measurement with pulmonary artery catheter (Vigilance) (CCO). Methods In 28 cardiac surgery patients, data were collected at 1 hour (T1), 2 hours (T2), 4 hours (T3), 8 hours (T4), 12 hours (T5), 24 hours (T6), 36 hours (T7), and 48 hours (T8) after ICU admission. Devices were only calibrated at start of the investigation period. To compute efect against time, at each time point, the CO values from LCO, FCO, PCO and CCO were subtracted, and compared with COtd (ICO). Efect of time was quantiied by calculating the slope values using linear regression. Slope values of the regression line were tested against a horizontal line (no efect). Results No change with time was found for CCO (slope = 0.02 l/minute/ hour, 95% CI –0.12 to 0.17, P = 0.763) nor for LCO (slope = 0.011 l/minute/ hour, 95% CI –0.11 to 0.03, P = 0.322). Time efect for PCO was (slope = –0.017 l/minute/hour, 95% CI –0.032 to –0.001, P = 0.036) and for FCO (slope = 0.029 l/minute/hour, 95% CI 0.003 to 0.055, P = 0.027). For the LCO system, the data range indicated by the 95% CI crosses the threshold value of 10% at 2, 12 and 24 hours, implying more than 2.5% of the data points are outside the chosen 10% limits at these time points (Figure 1). This occurs with PCO from 1 hour to 24 hours, with FCO at 4, 8, 12 and 24 hours, and with CCO at 4, 12 and 24 hours. Conclusions PiCCO and FloTrac/Vigileo showed an efect with time. For PiCCO, our indings are in accordance with the publications of Boyle and Hanzaoui. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S38 Figure 1 (abstract P106). Stability range of ±10% indicated by dashed lines. P107 A comparison in cardiac output data: a random efects model for repeated measures R De Wilde, B Geerts, P Van den Berg, J Jansen Leiden University Medical Center, Leiden, the Netherlands Critical Care 2010, 14(Suppl 1):P107 (doi: 10.1186/cc8339) Results The results of the random efects model on continuous cardiac output data are presented in Figure 1. Conclusions The variation of the diferences of the original measurement will be underestimated by this practice because the measurement error is, to some extent, removed. The bias between these two methods will not be afected by averaging the repeated measurements. Reference Introduction A random efects model can be used to estimate the withinsubject variation after accounting for other observed and unobserved variations, in which each subject has a diferent intercept and slope over the observation period. On the basis of the within-subject variance estimated by the random efects model, Bland–Altman plots can be created. Methods In 28 cardiac surgery patients, cardiac output data LiDCO™plus, PICCO, FloTrac/Vigileo pulse contour and CCO (PAC-Vigilance) was collected at 1 hour (T1), 2 hours (T2), 4 hours (T3), 8 hours (T4), 12 hours (T5), 24 hours (T6), 36 hours (T7), and 48 hours (T8) after ICU admission and compared against intermitted thermodilution COtd (ICO). Within patient variation was calculated using Linear Mixed Models (SPSS). Percentage error is calculated as: PE = [(2.SD of CO diference) / (COmean)] x 100%. 1. Figure 1 (abstract P107). Bland–Altman statistics from CO data: random efects model (LMM). Myles PS, Cui J: Br J Anaesthesia 2007, 99:309-311. P108 In vivo validation of a new transpulmonary thermodilution method to assess global end-diastolic volume and extravascular lung water K Bendjelid1, R Giraud1, N Siegenthaler1, F Michard2 1 Geneva University Hospitals, Geneva, Switzerland; 2Edwards Lifesciences, Nyon, Switzerland Critical Care 2010, 14(Suppl 1):P108 (doi: 10.1186/cc8340) Introduction The downslope time (DSt) is part of the equation used to derive global end-diastolic volume (GEDV) and extravascular lung water (EVLW) from a transpulmonary thermodilution curve. DSt may be afected by recirculation phenomena of the cold indicator, as those observed in case of valvular regurgitation. Our goal was to validate a new transpulmonary thermodilution method that does not depend on DSt. Methods Eleven anesthetized and mechanically ventilated pigs (90 to 110 kg) were instrumented with a central venous catheter and a right (PulsioCath; Pulsion, Munich, Germany) and a left (VolumeView; Edwards Lifesciences, Irvine, CA, USA) thermodilution femoral arterial catheter. The right femoral catheter was connected to a PiCCO2 monitor (Pulsion) and used to measure COp (cardiac output), GEDVp and EVLWp using the method based on the equation: GEDV = COp x (MTt – DSt). The left femoral catheter was connected to the EV1000 monitor (Edwards) and used to measure COe, GEDVe and EVLWe using the new method based on the equation: GEDVe = f (S2/S1) x COe x MTt, where S1 and S2 are respectively the maximum upslopes and down-slopes of the dilution curve. One hundred and thirty-seven measurements were done during inotropic stimulation (dobutamine), during hypovolemia (bleeding), during hypervolemia (luid overload), and after inducing acute lung injury (oleic acid). Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Results COp and COe ranged from 3.1 to 15.4 and from 3.4 to 15.1 l/ minute, respectively. COp and COe were closely correlated (r2 = 0.99), mean bias (± SD) was 0.18 ± 0.29 and percentage error was 7%. GEDVp and GEDVe ranged from 701 to 1,629 and from 774 to 1,645 ml. GEDVp and GEDVe were closely correlated (r2 = 0.79), mean bias was –11 ± 78 and percentage error was 14%. EVLWp and EVLWe ranged from 507 to 2379 and from 495 to 2,222 ml. EVLWp and EVLWe were closely correlated (r2 = 0.97), mean bias was –5 ± 72 and percentage error was 15%. Conclusions In animals, and over a very wide range of values, the new transpulmonary thermodilution method is as reliable as the PiCCO method to assess cardiac output, cardiac preload and lung water during inotropic stimulation, bleeding, volume loading and lung injury. P109 Cardiac index derived from arterial pressure waveform: uncalibrated analysis vs once-only calibrated analysis H Einwaechter, S Hiemer, M Treiber, B Saugel, V Phillip, RM Schmid, W Huber Klinikum rechts der Isar der TU München, Germany Critical Care 2010, 14(Suppl 1):P109 (doi: 10.1186/cc8341) Introduction As the need for recalibration and the best time point to recalibrate has been a matter of debate since the introduction of the PiCCO monitor (Pulsion, Germany), we set out to analyze the performance of its pulse contour (PC) analysis without recalibration over a 24-hour period. Methods We studied the cardiac index (CI) over a 24-hour period in eight nonoperative patients admitted to our ICU. Seven CI measurements (median number; every 4 hours) by thermodilution (TD) were performed in each patient (in triplicate), PC-derived data were recorded continuously. We used a special PiCCOplus monitor with a disabled auto-recalibrate feature; that is, TD did not lead to an automatic calibration of the PC analysis. Calibration was only performed manually once at the start of the analysis for each patient. Later TD measurements were recorded but had no efect on the CIPC. An additional comparison was performed using the FloTrac/Vigileo System (Edwards, USA), which does not need manual recalibration and instead recalibrates itself every 60 seconds based on the arterial waveform. The FloTrac/Vigileo monitor used was a secondgeneration device (software version 1.14). Both the pressure transducers of the PiCCO and the FloTrac were connected in series to the same femoral artery catheter. Results A total of 59 TD measurements of CI (CITD) were compared with FloTrac CI measurements (CIFloTrac) and PC-derived CI measurements (CIPC) from the PiCCO device. CITD ranged from 2.1 to 7.6 l/minute/m2 (mean 4.3 ± 1.39 l/minute/m2). PC (PiCCO) compared with TD: bias and precision (1.96SD of the bias) were 0.18 l/minute/m2 and ±1.35 l/minute/ m2, the percentage error was 30.9%. FloTrac compared with TD: bias and precision were –0.75 l/minute/m2 and ±1.79 l/minute/m2, the percentage error was 46.2%. The mean absolute value of the diference |CITD – CIPC| and |CITD – CIFloTrac| was 0.48 ± 0.49 l/minute/m2 for PiCCO pulse contour values and 0.97 ± 0.76 l/minute/m2 for FloTrac/Vigileo values, respectively. This higher diference of CIFloTrac from CITD was signiicant (P = 0.0002) and remained signiicant even when only data from the last time point (24 hours) was analyzed (P = 0.03). Conclusions PC-derived CI values obtained over a 24-hour period from the PiCCO device after only one manual calibration provide signiicantly better estimates of CI than measurements by the FloTrac/Vigileo device, even after a calibration-free interval of 24 hours. S39 good impact in terms of outcome [1], and less invasive systems have been proposed. Our aim was to compare the CO estimated by Vigileo/FloTrac with the blood low in thoracic aorta as measured by transoesophageal Doppler in patients undergoing open abdominal aortic aneurysm repair, during the aortic cross-clamping (AoX) phase. We have measured the Augmentation Index (AI), a parameter related to vascular stifness, using the applanation tonometry method, in order to have a better understanding of the efect of AoX on blood pressure waves. Methods We enrolled 10 consecutive patients (10 men; age 66 ± 6 years) undergoing elective open AAA repair (ASA II to III) under general anesthesia. Radial arterial access was used for semi-invasive determination of blood pressures and CO (APCO) with the Vigileo. An esophageal Doppler was positioned after clinical stabilization. Applanation tonometry was measured just before and after the aortic clamping. Results We found a signiicant (P <0.05) increase in CO reported by Vigileo/FloTrac system in the post-clamping phase, when compared with the pre-clamping and basal phases, while the blood low in thoracic aorta resulted decreased, according with the theory of redistribution of luids in the splanchnic venous vasculature [2]. There was an important contribution of the wave relection to the aortic pulse pressure wave after the AoX, as expressed by a signiicant increase in the AI. Conclusions The Vigileo/FloTrac system appears to overestimate CO after AoX when compared with the measure of blood low in thoracic aorta, and this result could be inluenced by the pulse pressure wave relection occurring after clamping. In high-risk surgical settings, other situations of rapid change of systemic resistance vessels could be similarly misread, thus suggesting the necessity of a more tailored Vigileo algorithm. References 1. 2. Shah MR et al.: Impact of the pulmonary artery catheter in critically ill patients: meta-analysis of randomized clinical trials. JAMA 2005, 294:1664-1670. Gelman S: The pathophysiology of aortic cross-clamping and unclamping. Anesthesiology 1995, 82:1026-1060. P111 Stroke volume index assessment using two minimal invasive devices during hemodynamic postoperative optimization M Costa, T Cecconet, P Chiarandini, L Pompei, S Tomasino, S Buttera, G Della Rocca University of Udine, Italy Critical Care 2010, 14(Suppl 1):P111 (doi: 10.1186/cc8343) Introduction Postoperative hemodynamic optimization has been proved to reduce morbidity in high-risk patients [1]. Nowadays stroke volume index (SVI) monitoring is available with diferent less invasive techniques that have shown diferent levels of agreement and precision with the pulmonary artery catheter [2]. The aim of this study was to evaluate agreement and precision between SVI obtained with a calibrated (LiDCO™plus; LiDCO Ltd, Cambridge, UK) and an uncalibrated pulse contour analysis device (FloTrac/Vigileo; Edwards Lifesciences, Irvine, CA, USA), in patients undergoing postoperative hemodynamic optimization. Methods Patients undergoing a hemodynamic optimization protocolized care according to a previous published trial [1] to reach an oxygen delivery P110 Cardiac output monitoring during abdominal aortic cross clamping: a comparison between Vigileo/FloTrac system and transoesophageal Doppler D Simion, M Lecca, M Dan, A Martini, N Menestrina, L Gottin University of Verona, Verona, Italy Critical Care 2010, 14(Suppl 1):P110 (doi: 10.1186/cc8342) Introduction Cardiac output (CO) monitoring is one of the key points in the hemodynamic evaluation of critically ill patients, and can be useful in various settings of high-risk surgery. There is a lack of evidence that the extensive use of invasive devices in the hemodynamic monitoring has a Figure 1 (abstract P111). Bland and Altman analysis. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 index >600 ml/minute/m2 after abdominal surgery were enrolled. After calibration of the LiDCO™plus, SVI data obtained from LiDCO™plus, and FloTrac/Vigileo (version 1.07) were recorded every 15 minutes for 6 hours. Agreement and precision between SVI obtained with LiDCO (SVILI) and SVI obtained with Vigileo (SVIFT ) were evaluated with Bland and Altman analysis. Results Thirteen patients (nine males, four females), mean age 68.5 (± 28.3) years were enrolled into the study. Two hundred and seventy SVI data pairs were analyzed. Bias was 1.79 ml/m2, with a precision (1.96SD of the bias) of 25.1 ml/m2 (Figure 1). Conclusions SVI obtained from the uncalibrated low-invasive, pulse contour analysis technique seems as accurate as the calibrated technique in a clinical hemodynamic protocolized setting to increase oxygen delivery in postoperative high-risk patients. References 1. 2. Pearse R, et al.: Crit Care 2005, 9:R687-R693. Hofer CK, et al.: Curr Opin Crit Care 2007, 13:308-331. P112 Non-invasive cardiac output monitoring in children: clinical validation Y Vandormael, T Vu, M Gewillig, D Vlasselaers University Hospitals Leuven, Belgium Critical Care 2010, 14(Suppl 1):P112 (doi: 10.1186/cc8344) Introduction Continuous noninvasive cardiac output (CO) provides valuable information for patient management. Non-invasive cardiac output monitoring (NICOM) measures CO based on chest bioreactance and is validated in adults [1]. Validated data in children are lacking. Our objective was to evaluate NICOM in children with pulmonary artery catheter thermodilution (PAC) as reference. Methods Paired CO values using NICOM and TD were recorded during cardiac catheterization in children with congenital heart disease. Children with intracardiac or extracardiac shunts were excluded. PAC was inserted through the femoral vein and CO was measured after bolus injection of 5 ml iced saline. NICOM was connected in accordance with the manufacturers’ directrix. Results Nineteen pairs of CO measurements were collected in nine patients. Mean age was 4.6 years (range: 0 to 12 years) and mean weight 16.8 kg (range: 4.8 to 34 kg). Cardiac diagnosis was dilated cardiomyopathy or interventional procedures. Mean CO values were 2.18 l/minute (PAC) and 1.88 l/minute (NICOM). Correlation between two methods was signiicant (r = 0.826; P = 0.0005). Bland–Altman analysis shows a mean diference between the reference method and NICOM of +0.33 l/minute. Ninety-ive percent of measurements were inside the limits of agreement (±1.96SD) but these limits were broad (–1.24 to 1.96 l/minute) (Figure 1). Conclusions CO measurements with NICOM and PAC show a signiicant correlation. Bland–Altman demonstrates an acceptable agreement; Figure 1 (abstract P112). Bland–Altman analysis. S40 however, the limits of agreement are broad. Depending on the CO range, NICOM reveals a trend to systematically overestimate or underestimate CO. Additional studies in larger and more heterogeneous pediatric patient populations are warranted for further validation. References 1. Squara P, et al.: Intensive Care Med 2007, 33:1191-1194. P113 Response of NICOM stroke volume to passive leg raising to predict luid responsiveness in critically ill patients with spontaneous breathing activity B Lamia1, A Cuvelier1, PL Declercq1, LC Molano1, MR Pinsky2, JF Muir1 1 Rouen University Hopsital, Rouen School of Medecine, Rouen, France; 2 University of Pittsburgh Medical Center, Pittsburgh, PA, USA Critical Care 2010, 14(Suppl 1):P113 (doi: 10.1186/cc8345) Introduction Volume responsiveness cannot be predicted by the respiratory variation in arterial pressure in hemodynamically unstable patients with spontaneous breathing activity. The NICOM device (Reliant®; Cheetah) (bioreactance technique) is a totally non-invasive hemodynamic monitoring technique for the measurement of stroke volume. Our objective was to test whether volume responsiveness could be predicted by the response of stroke volume measured by the NCOM device to passive leg raising (PLR) in patients with spontaneous breathing activity. Methods Prospective study in the respiratory critical care of a university hospital. Eleven patients with spontaneously breathing activity considered for volume expansion. An increase in stroke volume index (SVi) of 15% or more after volume expansion deined a responder patient. We measured the response of the bioreactance stroke volume to PLR and to saline infusion (500 ml over 15 minutes). Results The proportional changes in NiCOM-SVi induced by PLR were correlated with the proportional changes in NICOM-SVi induced by volume expansion (r = 0.67, P = 0.02). The proportional changes in NICOM-cardiac index (CI) induced by PLR were also correlated with the proportional changes in NICOM-CI induced by volume expansion (r = 0.63, P = 0.03). A PLR-induced increase in stroke volume of 9% or more predicted an increase in stroke volume of 15% or more after volume expansion with a sensitivity of 100% and a speciicity of 80%. Conclusions The response of NICOM-stroke volume to PLR was a good predictor of volume responsiveness. In our hemodynamically unstable patients with spontaneous breathing activity, luid responsiveness can be assessed totally non-invasively with a bioreactance device. P114 Global end-diastolic volume and its correlation to cardiac index inside and outside normal values W Huber, S Mair, B Saugel, V Phillip, H Einwaechter, R Schmid Klinikum rechts der Isar der Technischen Universität München, Germany Critical Care 2010, 14(Suppl 1):P114 (doi: 10.1186/cc8346) Introduction Transpulmonary thermodilution (TPTD)-derived volumetric parameters such as global end-diastolic volume (GEDI) and ELWI have been established as hemodynamic cornerstones for assessment of preload (GEDI) and pulmonary hydration. Normal values of GEDI have been created more than a decade ago based on studies in pre-selected patients. Therefore, it was the aim of our prospective study to investigate the correlation of GEDI to cardiac index (CI) in clinical routine. Methods Over a 6-month period all 1,574 routine TPTD measurements in 78 consecutive patients (APACHE II: 23.5 ± 8.6) of an internal ICU with a PiCCO catheter were prospectively documented and analysed: correlation (Spearman) and multiple regression analysis; SPSS 17.0. Results Including all 1,574 measurements, CI was univariately correlated to GEDI (r = 0.251; P <0.001), dPmax (r = 0.221; P <0.001) and heart rate (r = 0.102; P <0.001), but not to CVP (r = 0.001; P = 0.962). The correlation of GEDI, dPmax and heart rate to CI was conirmed in multivariate analysis (P <0.001 for all three variables). Changes in CI (Delta-CI) were univariately correlated to changes in GEDI (r = 0.414), dPmax (r = 0.240) and ELWI (r = 0.152; P <0.001 for all comparisons). In a multivariate analysis of all measurements, DeltaCI was independently associated with changes in GEDI (P <0.001), dPmax (P <0.001) and CVP (P = 0.017). Subgroup analysis of all measurements Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 with GEDI below the lower normal level 680 ml/kg/m2 demonstrated an independent association of CI to GEDI (P <0.001), dPmax (P <0.001) and ELWI (P = 0.041) but not to CVP. Similarly, Delta-CI was independently associated with changes in GEDI and dPmax (P <0.001). Similar results were found for the measurements with GEDI within the normal range (680 to 800 ml/kg/ m2): signiicant and independent correlation of CI to GEDI (P <0.017) and dPmax (P <0.001). Changes in CI were independently correlated to changes in GEDI (P <0.001), dPmax (P <0.001) and CVP (P = 0.035). Interestingly, even in measurements with GEDI >800 ml/kg/m2, CI was independently correlated to GEDI (P = 0.009) and dPmax (P <0.001). Changes in CI in this group were independently associated with changes in dPmax and GEDI (P <0.001).In the subgroup of measurements with GEDI >1,000 ml/kg/m2 there was no correlation of any parameter to CI, however changes in CI were independently correlated to changes in GEDI (P <0.001) and dPmax (P = 0.003). Conclusions GEDI and dPmax and their changes have an independent and positive correlation to CI and its changes even in patients with increased GEDI. P115 Relationship of stroke volume variation, pulse pressure variation and global end-diastolic volume in patients undergoing brain surgery A Rieß1, S Wolf2, C Lumenta2, L Schürer2, P Friederich1 1 Klinikum Bogenhausen, Department of Anesthesiology, München, Germany; 2 Department of Neurosurgery, München, Germany Critical Care 2010, 14(Suppl 1):P115 (doi: 10.1186/cc8347) Introduction Monitoring intravascular volume in patients with intracranial pathology is often mandatory for maintaining hemodynamic stability [1,2]. Cyclic changes in cardiac stroke volume [1,3] and pulse pressure induced by positive pressure ventilation as well as target values of global end-diastolic volume index (GEDVI) (ml/m2) [2] allow volume therapy guidance. The relationship between stroke volume variation (SVV) (%) and pulse pressure variation (PPV) (%), as well as between SVV or PPV and values of GEDVI has not been established in patients with intracranial pathology. Methods In this prospective investigation the correlation between dynamic and static hemodynamic parameters of 38 patients undergoing brain surgery was studied. Measurements were performed using the PiCCO technology. For statistical analysis, nonparametric correlation analysis and hypothesis testing were applied. Results SVV correlated signiicantly with PPV (r2 = 0.87, P <0.001). Neither SVV (r2 = 0.14, P = 0.13) nor PPV (r2 = 0.07, P = 0.81) correlated with GEDVI. Threshold values for SVV (9.5%, 11.6%) as well as for PPV (12.5%) allowed discrimination between groups with signiicantly diferent values of stroke volume index, while failing to discriminate between groups with signiicantly diferent values of GEDVI. Dichotomizing the patients into groups of GEDVI ≤680 ml/m2 and >680 ml/m2 resulted in groups with signiicantly diferent values of stroke volume index as well while failing to discriminate between groups with signiicantly diferent values of SVV and PPV. Conclusions Static (GEDVI) and dynamic (SVV, PPV) parameters of cardiac preload may relect diferent properties of the cardiovascular system. The combination of SVV, PPV, and GEDVI may ofer more precise information on the cardiovascular system than either parameter alone. References 1. 2. 3. S41 is validated as a predictor of volume response in several studies, but in patients ventilated with VT >8 ml/kg. One study has shown that the ΔPP of 12 to 13% does not predict volume response in patients ventilated with a low VT. We hypothesized that a lower cut-of value for ΔPP can predict volume response in patients with low VT. Methods Thirty-seven adult patients mechanically ventilated with a tidal volume <8 ml/kg (PBW), without cardiac arrhythmias, with a pulmonary artery catheter and a peripheral arterial catheter were included. An increase in cardiac index (thermodilution)) >15% output after a luid challenge (Crystalloid 1,000 ml or Colloid 500 ml) was considered a positive response. Results Seventeen patients were responders. The ROC curve showed that the best cut-of value for ΔPP was 10% (ROC area = 0.74, 95% CI: 0.51 to 0.9; sensitivity 53%, speciicity 95%, positive likelihood ratio 9.4 and negative 0.34).Twelve patients consisted of a heterogeneous group of patients (liver transplant, acute pancreatitis, aortic surgery). Among 25 septic shock patients, a ΔPP >10% showed a ROC area of 0.84 (sensitivity 78%, speciicity 93%). In any case, the greater ΔPP, the greater the luid response. ΔPP >10% was a better predictor than CVP or PAOP. Conclusions ΔPP has a limited value in patients ventilated with low VT. However, a ΔPP >10% may help identify septic shock patients that will respond to a luid challenge. References 1. Vincent JL, et al.: Pulse pressure variations to predict luid responsiveness: Inluence of tidal volume. Intensive Care Med 2005, 31:517-523. P117 Pre-ejection period is a reliable parameter to estimate cardiac preload in a hemorrhagic shock R Giraud, N Siegenthaler, JA Romand, K Bendjelid Hôpitaux Universitaires de Genève, Switzerland Critical Care 2010, 14(Suppl 1):P117 (doi: 10.1186/cc8349) Introduction We have already demonstrated that in mechanically ventilated patients, the respiratory change in the pre-ejection period (ΔPEP) is a reliable dynamic index for the prediction of increase in cardiac output after volume infusion [1]. However, in an animal study, Kubitz and colleagues showed that the pre-ejection period is not sensitive to the changes in intravascular volume status [2]. Methods This study investigated the inluence of changes in intravascular volume status on ΔPEP. In 17 pigs, ECG, arterial pressure and cardiac output derived from a Swan–Ganz catheter were recorded. Measurements were performed during normovolaemic conditions, after haemorrhage (25 ml/ kg) and following re-transfusion (25 ml/kg) with constant tidal volume (10 ml/kg) and respiration rate (15/minute). Berkenstadt H, et al.: Anesth Analg 2001, 92:984-989. Mutoh T, et al.: Stroke 2009, 40:2368-2374. Marik PE, et al.: Crit Care Med 2009, 37:2642-2647. P116 The value of pulse pressure variation to predict volume response in patients ventilated with low VT GF Friedman, CD Costa, SR Vieira, L Fialkow Hospital de Clínicas de Porto Alegre, Brazil Critical Care 2010, 14(Suppl 1):P116 (doi: 10.1186/cc8348) Introduction The prediction value of pulse pressure variation (ΔPP) in patients ventilated with low VT is not well studied. A ΔPP of 12 to 13% Figure 1 (abstract P117). Box plot representing pulse pressure variations (PPV) (%) and pre-ejection period variations (ΔPEP) (%) at the three times of the protocol. §P <0.05, †P <0.05. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Results At baseline, respiratory changes in pulse pressure (PPV) and ΔPEP were both <12%. PPV signiicantly correlated with ΔPEP (r = 0.96, P <0.001). Volume loss induced by haemorrhage increased PPV and ΔPEP. Moreover, during this state, PPV correlated with ΔPEP with a signiicant correlation coeicient (r = 0.88, P <0.001). Retransfusion signiicantly decreased PPV and ΔPEP and PPV signiicantly correlated with ΔPEP (r = 0.94, P <0.001) (Figure 1). Conclusions Available correlations between PPV and ΔPEP at each time of the study were observed, meaning that ΔPEP is a reliable parameter to estimate the changes in intravascular volume status. References 1. 2. Bendjelid K, Suter PM, Romand JA: The respiratory change in preejection period: a new method to predict luid responsiveness. J Appl Physiol 2004, 96:337-342. Kubitz JC, Kemming GI, Schultheib G, Starke J, Podtschaske A, Goetz AE, Reuter DA: The inluence of cardiac preload and positive end-expiratory pressure on the pre-ejection period. Physiol Meas 2005, 26:1033-1038 P118 Predictive value of pulse pressure variation for luid responsiveness after maneuver to change tidal volume in patients with protective ventilatory strategy F Machado, F Freitas, M Assuncao, B Mazza, M Jackiu Federal University of São Paulo, Brazil Critical Care 2010, 14(Suppl 1):P118 (doi: 10.1186/cc8350) Introduction After the early phase of sepsis, excessive luid administration may worsen pulmonary edema and prolong mechanical ventilation [1]. Accurately predicting luid responsiveness obviates unnecessary luid loading, and helps to detect patients who may beneit from a volume expansion. Pulse pressure variation (DPP) is a reliable predictor of luid responsiveness in mechanically ventilated patients only when tidal volume is at least 8 ml/kg [2]. The aim of this study was to evaluate the predictive value of DPP for luid responsiveness after a maneuver to change tidal volume to 8 ml/kg in patients ventilated with 6 ml/kg. Methods Prospective clinical study in 40 patients ventilated with 6 ml/kg after resuscitation phase of severe sepsis and septic shock. Fluid challenge was indicated by the attending physician (7 ml/kg of 6% hydroxyethyl starch 130/0.4). Complete hemodynamic measurements including DPP (DPP 6 ml/kg) were obtained at baseline. The tidal volume was then changed to 8 ml/kg and the DPP (DPP 8 ml/kg) was measured after 5 minutes. The ventilatory settings were returned to 6 ml/kg before luid challenge. Patients whose cardiac output (CO) increased by ≥15% were considered to be luid responders. Receiver operating characteristic (ROC) curve analysis was used to evaluate the predictive value of DPP. Results In 19 patients (responders), CO increased by >15% after luid infusion. Fluid responsiveness was better predicted with DPP 6 ml/kg (ROC curve area 0.92 ± 0.05) than with pulmonary artery occluded pressure (0.56 ± 0.09) and right atrial pressures (0.74 ± 0.08). Increasing tidal volume to 8 ml/kg did not improved prediction as the ROC curve area with DPP 8 ml/kg was 0.94 ± 0.03. The best cut-of values deined by the ROC curve analysis was 6.5% and 10.5% for DPP 6 ml/kg and DPP 8 ml/kg, respectively. Conclusions The maneuver to change tidal volume to 8 ml/kg in patients ventilated with protective ventilatory strategy to better predict luid responsiveness is not useful. Fluid responsiveness can be correctly predicted in patients ventilated with tidal volume of 6 ml/kg. References 1. 2. Wiedemann HP, et al.: N Engl J Med 2006, 354:2564-2575. De Backer D, et al.: Intensive Care Med 2005, 31:517-523. P119 Does stroke volume increase after a luid challenge? A study on the management of patients undergoing major head and neck free lap surgery: preliminary data L Wijayasiri, D Garewal, M Khpal, A Rhodes, A Dewhurst, M Cecconi St George’s Hospital, London, UK Critical Care 2010, 14(Suppl 1):P119 (doi: 10.1186/cc8351) Introduction Major head and neck surgery involving reconstructive free laps for oropharyngeal cancers are complex and prolonged operations S42 during which appropriate luid management can become diicult. Potential adverse efects of luid mismanagement in this group of patients include lap hypoperfusion related to hypovolaemia or lap oedema and deterioration in alveolar–arterial gradients related to excessive luid administration. This study looked at ongoing standard practice, to determine whether the use of a cardiac output monitor could improve luid management in this subset of patients. Methods Single-blinded, prospective observational study conducted on consecutive adult patients undergoing major head and neck reconstructive free lap surgery. All patients were anaesthetised by the same individual, using a standardised technique. Volume-controlled positive pressure ventilation was initiated in all patients. Patients received maintenance crystalloid luids at a rate of 5 ml/kg/hour. Additional luid challenges (250 ml crystalloid boluses given over 5 minutes) were administered at the discretion of the anaesthetist. A priori criterion of luid responsiveness was deined as an increase in stroke volume (SV) >10% as measured with the LiDCOrapid after a luid challenge. The anaesthetist was blinded to the LiDCOrapid data and observations were made by an independent investigator. Data were collected on: heart rate (HR), mean arterial pressure (mAP) and central venous pressure (CVP). Results Forty-seven luid boluses were assessed. The median age of the patients was 72 years (range 68 to 81 years) and their median weight was 71.2 kg (range 63 to 88 kg). The ventilatory set-up used a median tidal volume of 7 ml/kg (range 450 to 600 ml). Fifteen out of 47 (32%) of the luid challenges were positive when assessed against the change in stroke volume. When comparing the luid responders with the nonresponders, there were no diferences in HR (62 ± 10 bpm vs 62 ± 10 bpm), mAP (63 ± 6 mmHg vs 63 ± 7 mmHg) or CVP (8 ± 3 mmHg vs 10 ± 3 mmHg). Conclusions This preliminary report suggests that only 32% of luid challenges given in theatre were efective in increasing the SV >10% and potentially two-thirds of the luid challenges may have been detrimental. This can be seen only if SV is monitored continuously. If further data conirm this, LiDCOrapid may be useful to guide luid administration in order to optimise the SV, thereby minimizing the risk of luid overload. P120 Optimizing stroke volume and oxygen delivery in elective abdominal aortic surgery J Bisgaard1, E Rønholm1, T Gilsaa1, P Toft2 1 Kolding Hospital, Kolding, Denmark; 2Odense University Hospital, Odense, Denmark Critical Care 2010, 14(Suppl 1):P120 (doi: 10.1186/cc8352) Introduction Patients undergoing elective abdominal aortic surgery (EAAS) are at risk of developing complications due to preoperative co-morbidity, surgical trauma, blood loss and inlammatory injury [1]. Individualized goal-directed therapy (IGDT) has been proposed to improve outcome in patients undergoing high-risk surgery [2]. The aim of this study was to investigate whether IGDT, targeting stroke volume (SV) and oxygen delivery (DO2), can be performed safely in EAAS. Methods Sixty-three EAAS patients were randomized to IGDT or conventional therapy. The LiDCO™plus system was used for SV and DO2 monitoring. SV was optimized by 250 ml luid challenges intraoperatively and the irst 6 hours postoperatively. DO2 was optimized 6 hours postoperatively targeting a DO2I level of 600 ml/min/m2, by infusion of dobutamine, if necessary. Hemodynamic data were collected at baseline (t0) preoperatively (t1), before aortic cross-clamping (t2), at the end of surgery (t3), and the irst 6 hours postoperatively (p1 to p6). All patients were monitored with ivelead ECG during dobutamine infusion and dosage was reduced at signs of ischemia or heart rate >20% above baseline. Dobutamine dosage was limited to a maximum of 10 μg/kg/minute. Results The mean SVI level was 19.4% higher at p4 to p6 in the IGDT group compared with the control group (P = 0.02), and 12.1% higher in the entire intervention period (t1 to p6) (P = 0.07). The mean DO2I was 18.0% higher at p4 to p6 (P = 0.01) and 12.9% higher in the entire intervention period (t1 to p6) in the IGDT group (P = 0.03). Mean arterial pressure and heart rate did not difer signiicantly (P = 0.12 and P = 0.21). There was no diference in the frequency of postoperative cardiac complications between the groups. Conclusions The results of this study demonstrate that IGDT targeting SV and DO2 can be performed safely in patients undergoing EAAS. Whether this intervention is beneicial is being evaluated in the current study. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S43 References 1. 2. Dardik et al.: Results of elective abdominal aortic aneurism repair in the 1990s: A population-based analysis of 2335 cases. J Vasc Surg 1999, 30:985-995. Bundgaard-Nielsen et al.: Monitoring of perioperative luid administration by individualized goal-directed therapy. Acta Anaestesiol Scand 2007, 51:331-340. P121 Oxygen saturation determined from the mouth is an early indicator of central hypovolemia in humans A Lima, M Alamyar, C Ince, J Bakker Erasmus MC University Medical Centre, Rotterdam, the Netherlands Critical Care 2010, 14(Suppl 1):P121 (doi: 10.1186/cc8353) Introduction Studies have suggested that tissue oxygenation (StO2) measured on the thenar muscle is not sensitive to track acute changes in hemodynamics due to reductions in central blood volume. We aimed to investigate the feasibility of StO2 measurements in the mouth as a quantitative indicator comparable with StO2 measurements obtained from the thenar eminence during changes in central blood volume (CBV). Methods We performed a head-up tilt (HUT) test in 10 healthy volunteers as an experimental model to reduce CBV. StO2 was continuously measured using two devices (InSpectra model 650): a multiple depth optical probe was placed over the thenar eminence (15 and 25 mm) and a 1-mm probe was placed in the mouth. Subjects were placed on an electrically driven tilt table with a footboard. After 5 minute baseline measurements in the supine position, the table was tilted up to 70° and returned to the supine position after 10 minutes. StO2 readings were analyzed at the lowest stroke volume value. Results All subjects (mean age: 23 ± 6; six males) tolerated well the supine and head-up positions. Cardiac output signiicantly decreased in the HUT position; simultaneous decrease in StO2 was observed in the mouth, but not in the thenar. The general results of the HUT test are shown in Tables 1 and 2. Table 1 (abstract P121). Hemodynamics in the baseline and in the head-up tilt (HUT) HR MAP CO Baseline HUT 69 91 5.6 85* 93 4.9* *P <0.05 vs baseline. Table 2 (abstract P121). StO2 in the baseline and in the head-up tilt (HUT) Baseline 76 ± 6 76 ± 5 88 ± 3 HUT Baseline 2 StO2 15 thenar 75 ± 6 75 ± 6 78 ± 3* 78 ± 7 78 ± 8 87 ± 3 StO2 25 thenar StO2 buccal *P <0.05 vs baseline 1 and 2. Conclusions Near-infrared spectroscopy can be used in the mouth to track changes in central blood volume. Our results showed that buccal StO2 is an earlier indicator of acute hemodynamic responses to the HUTinduced central hypovolemia than thenar StO2. P122 Plethysmographic indices as predictors of luid responsiveness: a meta-analysis CM Marano, FC Cavallaro, CS Sandroni, AD Dell’Anna, MA Antonelli Catholic University School of Medicine, Rome, Italy Critical Care 2010, 14(Suppl 1):P122 (doi: 10.1186/cc8354) Introduction The aim of the study was to assess the ability of respiratory variations in pulse oximetry plethysmographic waveform amplitude (ΔPOP) to predict the increase of cardiac output (CO) after luid infusion (luid responsiveness). Methods Two authors independently performed a search iterated until November 2009 in MEDLINE, Embase and Cochrane Database using keywords: ‘luid OR preload OR volume responsiveness’, ‘cardiovascular monitoring’, ‘luid challenge’, ‘functional hemodynamic monitoring’, ‘dynamic indices OR indexes’, ‘delta POP’, ‘pleth index’, ‘plethysmographic waveform’. Predictive value of ΔPOP was estimated by: diference in mean value of ΔPOP between responders and nonresponders; correlation coeicient between pre-infusion ΔPOP and CO increase after luids; and sensitivity, speciicity and area under the ROC curve (AUC) for ΔPOP to predict a responder state. A meta-analysis was performed using Comprehensive Meta-Analysis v. 2.2. Pooled values of diagnostic odds ratio (DOR), sensitivity, speciicity and summary ROC (SROC) curve were calculated using MetaDiSC v. 1.4. Heterogeneity was evaluated with Q and I2 tests. Results From the initial dataset of 839 records we identiied six articles [1-6] on 135 patients to whom 195 luid boluses were administered. All patients were in sinus rhythm and adapted to a ventilator. An increase of cardiac index or stroke volume index >10 to 15% deined responders. Mean responder rate was 58.9%. Pooled diference in mean was 10% (95% CI 5.8 to 14.2), correlation coeicient 0.59 (0.41 to 0.73), AUC 0.85 (0.76 to 0.94), sensitivity 81.1% (72.5 to 87.9), speciicity 78.6% (68.3 to 86.8), DOR 21.7 (6.3 to 74.4), area under SROC 0.88 (0.80 to 0.96). The best threshold value for identiication of responders was 9.5 to 15%. Heterogeneity was signiicant for all evaluations. Conclusions ΔPOP is a non-invasive dynamic parameter able to predict luid responsiveness with only a moderate level of accuracy. The main limitation of this analysis is heterogeneity between included studies. References 1. 2. 3. 4. 5. 6. Cannesson M, et al.: Anesthesiology 2007, 106:1105-1111. Cannesson M, et al.: Br J Anaesth 2008, 101:200-206. Feissel M, et al.: Intensive Care Med 2007, 33:993-999. Wyfels PA, et al.: Anesth Analg 2007, 105:448-452. Natalini G, et al.: Anesth Analg 2006, 103:1478-1484. Solus-Biguenet H, et al.: Br J Anaesth 2006, 97:808-816. P123 Maintenance of cardiac index within normal range is associated with mortality reduction in patients undergoing major urological surgery PS Szturz, JM Maca, JT Tichy, PS Sukenik, VC Chylek, PS Sklienka, JJ Jahoda, RK Kula Faculty Hospital Ostrava, Czech Republic Critical Care 2010, 14(Suppl 1):P123 (doi: 10.1186/cc8355) Introduction Hemodynamic optimisation based on low variables allows an early detection and correction of possible occult organ hypoperfusion in patients undergoing major surgery. Shoemaker described a markedly decreased cardiac index (CI) in nonsurvivors, which remained signiicantly below the values compared with survivors during the surgery. The aim of this study was to evaluate the length of ICU stay, overall in-hospital stay and the postoperative outcome in a group of patients undergoing major urological surgery, while the CI is maintained within the normal range during intraoperative period. Methods Patients were randomised into groups the day before surgery – conventional management group (decision about luid therapy and vasoactive support was based on internal guidelines to preserve normal macrohemodynamic variables), and protocol group. Each patient in the protocol group received an oesophageal Doppler probe (TED) (Hemosonic 100; Arrow International, USA) after the start of general anaesthesia and then hemodynamic optimisation (luid management and vasoactive drugs), according to TED variables, was performed to keep CI between 2.6 and 3.8 l/minute/m2. Results We enrolled 230 patients. The control group: n = 115 and the protocol group: n = 115. High-risk criteria surgery was fulilled in 43% patients in protocol group and 45% in control group. There were no signiicant diferences in baseline variables between both groups (age, gender, length of surgical procedure, estimated blood loss and also in intraoperative values of MAP and CVP). In the protocol group was observed a high frequency of CI <2.6 l/minute/m2 after induction of anesthesia 75% with fast recovery of CI. The volume of luids (Ringer’s solution and HES 6% 130/0.4) administered during surgery was lower in the control group (medians: 2,800 ml vs 3,800 ml, P <0.05). Amount of used blood units (RBC 71 vs 133, P = 0.001; FFP 71 vs 142, P <0.001) was higher in control group. Signiicant diferences have also been found in the use of vasoactive Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S44 Figure 1 (abstract P124). Functional capillary density. Dotted line, median. agents. Total number of postoperative complications (P <0.001), the ICU stay and overall in-hospital stay (medians: 2 vs 3 days, P = 0.041, and 9 vs 11 days, P = 0.014), in-hospital mortality (2.6% vs 10.4%, P = 0.029) were in favour of the protocol group of patients. Conclusions Hemodynamic optimisation guided by TED can improve postoperative outcome in patients after major urological surgery. Maintaining normal values of CI is an applicable target of intraoperative therapeutic intervention. P124 Efect of a preload challenge on peripheral perfusion in critically ill patients E Klijn, S Niehof, J Bakker, C Ince, J Van Bommel Erasmus Medical Center, Rotterdam, the Netherlands Critical Care 2010, 14(Suppl 1):P124 (doi: 10.1186/cc8356) Introduction Fluid therapy in ICU patients serves to maintain tissue perfusion and is directed at increasing cardiac stroke volume (SV) through an increase in preload: luid responsiveness. Although there is increasing evidence that the regional blood low cannot be predicted from global hemodynamic measurements, the relation between SV and parameters of peripheral perfusion is not clear. The aim of our study was to evaluate the efect of an increase in preload on commonly used parameters of peripheral perfusion. Methods Hemodynamically unstable patients with clinically suspected luid responsiveness underwent a passive leg raising (PLR) test, which consisted of 5 minutes of rest in a semirecumbent position of 30°, followed by 5 minutes PLR (lower limbs elevated at 30° and trunk in supine position). SV was measured continuously by pulse contour analysis using PiCCO (Pulsion). Peripheral perfusion was measured continuously with sidestream dark ield imaging (sublingual area) and laser Doppler lowmetry (LDF) (inger). Results Sixteen patients (age: 63 years (55 to 72), APACHE II: 25 (20 to 28), SOFA: 10 (7 to 13)) were included in our study. Of these 16 patients, six (38%) increased their SV by >10% in response to a PLR. Flow indices (LDF and sublinguale microcirculatory low) did not change. However, there was a trend in increase of the functional capillary density in the responders (see Figure 1). Conclusions These data suggest that increasing SV in hemodynamically unstable patients might improve peripheral perfusion, however only in the sublingual area and not in all patients. There was no relation between systemic circulation and peripheral perfusion: it remains to be investigated whether optimizing SV actually results in improved tissue perfusion. P125 Distensibility index of inferior vena cava diameter in ventilated septic and trauma patients with shock N Parenti1, D Sangiorgi2, A Pigna3, C Coniglio4, F Cancellieri4, G Gordini4, R Melotti3, G Di Nino3 1 Hospital Santa Maria della Scaletta Imola, Bologna, Italy; 2Università, Bologna, Italy; 3Policlinico Sant’Orsola, Bologna, Italy; 4Ospedale Maggiore, Bologna, Italy Critical Care 2010, 14(Suppl 1):P125 (doi: 10.1186/cc8357) Introduction We evaluated the distensibility index of the inferior vena cava (dIVC%) in ventilated septic and trauma patients with shock before and after luid therapy. There are no data on this index in patients in shock post trauma. Methods This is a prospective study conducted in two ICUs between September 2008 and May 2009. Inclusion criteria were: shock (systolic arterial pressure below 90 mmHg and/or perfusion of vasopressor amines) related to severe sepsis or to trauma. The inferior vena cava diameter at end-expiration (IVCDmax) and at end-inspiration (IVCDmin) was measured by echocardiography using a subcostal approach. The distensibility index of the IVC was the ratio of IVCDmax – IVCDmin / IVCDmin expressed as a percentage (dIVC%). Cardiac index (CI) was calculated by analysis of the arterial pressure wave (FloTrac/Vigileo; Edwards). Measurements were performed at baseline and after a volume expansion using 7 ml/kg colloid and 20 ml/kg crystalloid for septic and trauma patients, respectively. Patients were separated into responders (increase in CI ≥15%) and nonresponders (NR) after luid therapy. The Wilcoxon and Mann–Whitney tests were used to compare paired values. Statistical signiicance was tested at an α level of 0.05. Results Eleven patients in shock (ive septic, six trauma; six responder, ive NR) were included. The median age was 62 years (range 28 to 78 years) and mean SAPS II score was 52 ± 30 SD. There were no signiicant diferences between responders (R) and NR regarding age, gender, and risk scores. Among all patients, at baseline, median CI and dIVC% were 2.6 l/minute/ m2 and 29%, respectively. Volume expansion signiicantly increased the median CI from 2.6 (2 to 3.3) to 3 (2.1 to 4) l/minute/m2 (P = 0.005) and decreased dIVC% from 29.4% to 12.6% (P = 0.003). The median dIVC% in R was higher than NR: 31.3% vs 17% (P <0.05). Fluid therapy decreased more dIVC% in R than in NR: R 31% to 12% (P = 0.03), NR 17% to 12% (P = 0.04). The dIVC% showed similar trend in both groups of septic shock (SS) and trauma shock (TS) patients before and after luid therapy: dIVC% 27% in SS and 24% in TS before luid therapy; 15% in SS and 11% in TS after therapy. Conclusions Our data suggest that dIVC% is a sensitive index of luid responsiveness in septic and trauma patients in shock. Limitations: few patients. References 1. Barbier C, et al.: Respiratory changes in inferior vena cava diameter are helpful in predicting luid responsiveness in ventilated septic patients. Intensive Care Med 2004, 30:1740-1746. P126 Aortic dP/dtmax accurately relects left ventricular contractility when efective preload independence is achieved P Morimont1, B Lambermont1, T Desaive1, N Janssen1, G Chase2, V D’Orio1 1 University of Liege, Belgium; 2University of Canterbury, New Zealand Critical Care 2010, 14(Suppl 1):P126 (doi: 10.1186/cc8358) Introduction Myocardial depression occurs in 40% of patients presenting with sepsis. In critically ill patients, the peak irst derivative of aortic pressure (Ao_dP/dtmax) derived from a luid-illed catheter has been commonly used by clinicians for decades to assess directional change in left ventricular (LV) contractility. However, this parameter remains questionable because of its preload sensitivity. The aim of this study was to test whether Ao_dP/dtmax represents an accurate method for assessing LV contractility when preload independence, based on dynamic indices, is achieved. Methods LV pressure–volume data obtained with a conductance catheter and invasive aortic pressure obtained with a luid-illed catheter were continuously recorded in six anaesthetized and mechanically Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S45 Conclusions CCE demonstrated to be a very sensitive estimation of cardiovascular impedance since it shows a signiicant improvement after the valvuloplasty in spite of unchanged values of both SW and MW. In other words, the energy expenditure of the whole cardiovascular system signiicantly reduced after the aortic valve stenosis is corrected. Moreover, our data strongly suggest that peripheral dP/dtmax is deeply afected by aortic valve stenosis. References 1. 2. 3. Figure 1 (abstract P126). Correlation between Ees and Ao_dP/dtmax when PPV <11%. Incidence of ICR-BSI in WCNN intensive therapy unit. ventilated pigs. After a stabilization period, endotoxin was infused to induce septic shock. Fluid administration was continuously controlled by preload responsiveness by holding pulse pressure variation (PPV) <13%. Catecholamines were transiently administrated during shock. Ao_dP/dtmax was compared with end-systolic elastance (Ees), the gold standard method for assessing LV contractility. Results Endotoxin-induced septic shock and catecholamine infusion lead to signiicant variations in LV contractility. The best correlation (r2 = 0.76) and agreement between Ao_dP/dTmax and Ees were obtained when PPV <11% (Figure 1). Conclusions Ao_dP/dTmax is a minimally invasive and accurate method for assessing LV contractility when efective preload independence, deined as PPV <11%, is achieved. References 1. 2. Sharma AC: Shock 2007, 28:265-269. Pinsky MR, et al.: Curr Opin Crit Care 2005, 11:235-239. P127 Cardiac cycle eiciency: a new index for cardiac work estimation tested during aortic valve plasty S Romagnoli, M Romano, C Lazzeri, G Santoro, F Meucci, D Quattrone, D Dini, A De Gaudio Careggi Hospital, Florence, Italy Critical Care 2010, 14(Suppl 1):P127 (doi: 10.1186/cc8359) Introduction The pressure recording analytical method (PRAM) is the only pulse contour method that does not need any calibration since it estimates in vivo, beat to beat, the impedance of the cardiovascular system [1-3]. Cardiac cycle eiciency (CCE) is a novel parameter that is directly related to the cardiovascular impedance. Since the aortic valve contributes to impedance, we hypothesized during an aortic valvuloplasty, performed for severe aortic stenosis, the cardiovascular impedance may decrease by the reduction of the transvalvular gradient. Methods In a cath lab, ive consecutive patients undergoing aortic valve plasty for severe aortic stenosis were monitored by means of PRAM during the procedure. Systolic (SAP), diastolic, and mean (MAP) arterial pressures, stroke volume (SV), heart rate (HR), cardiac output (SV x HR), CCE, and dP/ dtmax were continuously collected and afterwards analyzed. The stroke work (SW = SV x MAP) and minute work (MW = SBP x CO) were also measured. Results After the ballooning maneuver (valvuloplasty), the maximal gradient measured with intraventricular and intraaortic catheters signiicantly decreased (146 (37) vs 43 (12) mmHg; P <0.0001). The CCE signiicantly improved from –0.72 (0.4) to 0.02 (0.19) U; P <0.0001. Peripheral dP/dtmax increased from 0.8 (0.27) to 1.16 (0.23) mmHg/ms; P = 0.001, while SW and MW did not show substantial modiications (4.06 (1.03) vs 4.02 (1.4) l x mmHg; NS, and 549.8 (111.5) vs 544.6 (153.4) l x mmHg; NS, respectively). Romagnoli S, Romano SM: Estimation of hemodynamic parameters by arterial waveform: available technologies. Anesth Analg in press. Maus TM, Lee DE: Arterial pressure-based cardiac output assessment. J Cardiothorac Vasc Anesth 2008, 22:468-473. Romano SM, Pistolesi M: Assessment of cardiac output from systemic arterial pressure in humans. Crit Care Med 2002, 30:1834-1841. P128 Nonocclusive mesenteric ischemia following cardiothoracic surgery N Kiyonaga, T Yasuda, T Yonemitsu, M Nagaoka, T Oryoji, M Nakahara, N Okayama, T Kikuchi, T Imabayashi, Y Kakihana, Y Kanmura Kagoshima University Hospital, Kagoshima City, Japan Critical Care 2010, 14(Suppl 1):P128 (doi: 10.1186/cc8360) Introduction Nonocclusive mesenteric ischemia (NOMI) following cardiac surgery carries a high mortality. This disease is diicult to diagnose. Early diagnosis is thought to be of paramount importance as the only chance of improving the survival rate in these patients. Therefore, we were retrospectively studied all cases of NOMI to evaluate what were the sensitive markers and what were the risk factors contributing to the occurrence of NOMI. Methods We retrospectively reviewed 279 patients undergoing cardiothoracic surgery from August 2007 to July 2008. Six of these patients (2.2%) developed NOMI postoperatively and the data for them were retrospectively evaluated in detail. Results In all cases of NOMI, they were diagnosed at laparotomy. The mean age was 69.7 years (50 to 83 years old), and the male:female ratio was 1:1. One patient received of-pump coronary artery bypass surgery, and ive underwent thoracic aortic surgery. Hemodialysis was initiated in one of six patients before operation, while the continuous hemodiailtration was initiated in all patients postoperatively. After operation, high-dose catecholamines were necessary in ive of six patients for long periods because of severe hypotension. In four of six patients, abdominal pain was the presenting symptom. The rest of two patients had a nonspeciic presentation because they were ventilated and sedated. All patients presented abdominal distension and their abdominal X-rays showed paralytic ileus features. The serum values of AST, LDH, CK, and lactate were slightly elevated in most patients. Five of six patients died from septic shock and multiple organ failures, and the mortality rate of patients with NOMI was 83%. Potential risk factors contributing to the occurrence of NOMI and sensitive markers might be the following: continuous hemodiailtration (6/6); hypotension (5/6); high-dose catecholamines (5/6); dehydration (6/6); abdominal pain (4/6); paralytic ileus patterns of abdominal X-rays (6/6). Conclusions The increase of NOMI incidence following cardiothoracic surgery might be related to continuous hemodiailtration, hypotension, dehydration, and uses of high-dose catecholamines. Identiication of patients at NOMI risk and prevention of hypovolemic hypotension and use of vasodilator may help to reduce the incidence of NOMI. References 1. Klotz S, Vestring T, Rotker J, et al.: Dagnosis and treatment of nonocclusive mesenteric ischemia after open heart surgery. Ann Thorac Surg 2001, 72:1583-1586. P129 Etiology, comorbidity and prognosis of hospitalized patients with congestive heart failure Y Zhao, J Li, Q Xue, L Gao, Q Xu, X Wu Institute of Geriatric Cardiology, Beijing, China Critical Care 2010, 14(Suppl 1):P129 (doi: 10.1186/cc8361) Introduction Congestive heart failure (CHF) is a growing public health problem in China, mainly because of aging of the population and the Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 increased prevalence of CHF in the elderly. The aim of present study was to investigate the major causes, comorbidities and in-hospital mortality of patients with CHF. Methods A retrospective study was performed in 6,960 patients (4,352 males, 2,608 females) with a validated primary discharge diagnosis of CHF hospitalized from 1 January 1993 through 31 December 2007, at Chinese PLA General Hospital in Beijing. The patients were divided into ive groups based on the number of etiologies and comorbidities from one to ive or more than ive. A comparative analysis was performed to explore the major causes, comorbidities and in-hospital mortality of patients among the groups. Results The mean (± SD) age of patients was 53 ± 17 years in the onecomorbidity group, 60 ± 16 years in the two-comorbidity group, 65 ± 14 years in the three-comorbidity group, 70 ± 13 years in the fourcomorbidity group and 72 ± 11 years in the ive-comorbidity group. The major causes of hospitalized patients with CHF were coronary artery disease (44.9%), vavular heart disease (27.5%), cor pulmonale (9.6%) and cardiomyopathy (7.4%). The comorbidities of CHF were hypertension (38.6%), atrial ibrillation (23.1%), diabetes mellitus (18.3%), pneumonia (11.6%) and renal failure (7.1%). The single comorbidity was predominant in younger patients while multiple comorbidity was predominant in the elderly (P <0.001). The most common single etiology was vavular heart disease, the most common triple etiology was coronary artery disease complicated with hypertension and diabetes mellitus. Cox regression analysis showed higher hospital mortality rates associated with increased numbers of etiology and comorbidity (hazard ratio (HR) from 0.98, 95% CI 0.71 to 1.36 to HR 1.59, 95% CI 1.23 to 2.05, to HR 1.90, 95% CI 1.43 to 2.51, to HR 2.47, 95% CI 1.81 to 3.35, P <0.001). Conclusions This study demonstrates that the older a hospitalized patient with CHF is, the more comorbidities they have. The major causes and comorbidities of hospitalized patients with CHF are coronary artery disease, vavular heart disease, cor pulmonale, cardiomyopathy, hypertension, atrial ibrillation, diabetes mellitus, pneumonia and renal failure. The single etiology or comorbidity is predominant in younger patients, while multiple etiology or comorbidity is predominant in the elderly. A higher in-hospital mortality rate of CHF is associated with an increased number of etiologies and comorbidities. P130 Factors associated with intensive care morbidity following surgical repair of tetralogy of fallot A Aralihond, A Krishnaiah, B Mimic, K Brown Great Ormond Street Hospital, London, UK Critical Care 2010, 14(Suppl 1):P130 (doi: 10.1186/cc8362) Introduction The outcome of surgical repair of tetralogy of fallot (TOF) is a useful benchmark for the assessment of congenital cardiac surgical programs. The aim of this study was to describe postoperative morbidity following TOF repair and assess the factors linked to a longer duration of postoperative ventilation. Methods Retrospective study of all patients admitted to cardiac intensive care between January 2003 and December 2008 following classic TOF repair. More complex repairs were excluded. Factors were investigated for a relationship with intubation hours using linear regression analysis. Intubation hours were log transformed for the analysis since the data were skewed. Results A total of 174 children were included, 97 (56%) male, of whom 31 (18%) had previous palliation with a BT shunt and 23 (13%) had extra medical problems. The median age at repair was 8.9 (range 1.6 to 112.8) months and the median weight was 8.2 (3.5 to 28.5) kg. The median cardiopulmonary bypass (CPB) time was 101 (42 to 292) minutes and 94 (54%) required transannular patch. The median postoperative intubation time was 23 (0 to 566) hours and 11 patients (6%) did not require postoperative ventilation. The median ICU stay was 66 (13 to 791) hours and there was one early death before hospital discharge. One hundred and seventy (95%) patients received an inodilator. Postoperative complications included renal failure and luid overload requiring peritoneal dialysis (PD) in 31 (17%); junctional ectopic tachycardia (JET) in 29 (16%); other arrhythmias in 10 (6%), delayed chest closure in six (3%) of which two had emergency mediastinal exploration due to bleeding and ECMO in one patient. A multiple regression model for the outcome measure intubation S46 hours indicated that younger age at repair (P = 0.03), associated medical problems (P = 0.04), longer CPB time (P = 0.057), JET, PD, noradrenalin use and adrenaline use (P <0.01 for all) were independently linked with longer postoperative ventilation times. Conclusions Younger children, those with extra medical problems and children that required higher levels of inotropes (probably relecting low cardiac output syndrome), had longer intubation times. The commonest and most important complications that inluenced duration of ventilation were JET and PD. In our series, mortality and length of stay were comparable with other published data. P131 Sildenail attenuates pulmonary vascular remodeling and upregulates Kv1.5 mRNA expression in pulmonary hypertension secondary to left-to-right shunt in rats L Hu, LH Tan Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Critical Care 2010, 14(Suppl 1):P131 (doi: 10.1186/cc8363) Introduction Sildenail is a phosphodiesterase-type-5 inhibitor and selectively decreases pulmonary artery pressure. So far, the mechanism underlying sildenail’s efects on pulmonary vascular remodeling and potassium channel activity in pulmonary artery smooth muscle cells (PASMCs) has not been clearly addressed in pulmonary hypertension secondary to increased pulmonary blood low. Methods A total of 27 male SD rats were randomly divided into a sham group (n = 9), a shunt group (n = 9) and a shunt + sildenail group (n = 9). A left-to-right shunt was established by performing an abdominal aorta to inferior vena cava istula both in the shunt group and the shunt + sildenail group. Rats in the shunt + sildenail group received oral sildenail 10 mg/kg/ day, whereas the rats in the sham group and the shunt group were fed with normal saline of the same volume. Eleven weeks later, mean pulmonary artery pressure (mPAP) was measured. Meanwhile, the ratio of right ventricular mass to left ventricular plus septal mass (RV/(LV+S)) was detected as a marker of the degree of right ventricular hypertrophy. The relative medial thickness (RMT) of middle and small pulmonary muscularized arteries was calculated as a sign of pathological changes of pulmonary vasculature. The voltage-gated potassium channel Kv1.5 mRNA expression of pulmonary vasculature was detected using real-time PCR. Results Eleven weeks later, the rats in the shunt group developed pulmonary hypertension as evidenced by signiicantly increased mPAP, RV/(LV+S), as well as higher RMT of middle and small pulmonary muscularized arteries (all P = 0.01). In addition, the rats in shunt group had decreased Kv1.5 mRNA expression in pulmonary vasculature (P = 0.01). The rats in the shunt + sildenail group had a signiicantly decreased mPAP, and RV/(LV+S) ratio, and a lower RMT as well (all P = 0.01), whereas the levels of Kv1.5 mRNA expression were signiicantly upregulated (P = 0.01). Furthermore, there were no statistically signiicant diference in mPAP, in RV/(LV+S) ratio, RMT of middle and small pulmonary muscularized arteries and Kv1.5 mRNA expression between the shunt + sildenail group and the sham group (all P = NS). Conclusions Oral sildenail attenuated pulmonary vascular remodeling and upregulated Kv1.5 mRNA expression in the rats with pulmonary hypertension secondary to left-to-right shunt. P132 Validation of echocardiographic indices of right ventricular afterload: an experimental, open pericardium pig model A Knook, D Reis Miranda, J Van Bommel, A Bogers, D Duncker, D Gommers, J Bakker Erasmus Medical Centre, Rotterdam, the Netherlands Critical Care 2010, 14(Suppl 1):P132 (doi: 10.1186/cc8364) Introduction Pulmonary vascular resistance (PVR) has been used to assess right ventricular afterload; however, this is considered meaningless due to several physiologic shortcomings. Echocardiography has often been used to assess right ventricular (RV) afterload, but this has never been validated as an index of RV afterload. The purpose of this study is to evaluate echocardiographic indices of RV afterload in an experimental, open-pericardium pig model with induced, variable main pulmonary artery stenosis. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Methods Eleven anesthesized pigs were instrumented for the measurement of arterial blood pressure, central venous pressure, RV and pulmonary pressure. An ultrasonic lowprobe (MA14PAX; Transonic) was positioned on the main pulmonary artery to obtain pulmonary low. Distal to the lowprobe, a balloon-occluder was positioned facilitating gradual constriction of the pulmonary artery. To obtain a stepwise pressure diference increment over the banding of 10 mmHg at each measurement, we gradually inlated the balloonoccluder. After 10 minutes, all invasive hemodynamic data were registered and an epicardial echocardiography was performed to obtain tricuspid low velocities, isovolumetric and isovolumetric relaxation time. To calculate the TEI index during one heartbeat, echocardiographic measurements were synchronized with lowprobe measurements to obtain ejection time. The E/E΄ ratio was obtained with tissue Doppler echocardiography of the lateral tricuspid annulus. All echocardiographic measurements were performed in triple and averaged. The ejection period and mean pulmonary acceleration and cardiac output were calculated from the pulmonary low curve derived from the ultrasonic lowprobe. Resistance over the pulmonary banding was calculated by pressure gradient divided by cardiac output. Results Of the 11 pigs, two pigs died prematurely, one inferior caval vein rupture, and one due to asystole while inserting the pulmonary artery catheter. After pulmonary banding, central venous pressure did not increase signiicantly. Mean acceleration correlated with the resistance over the banding (r = 0.59, P <0.0001). The TEI index and E/E΄ neither correlated with the pressure gradient over the banding nor low. Conclusions Mean acceleration correlated with RV afterload in this model. P133 Activation of apoptotic pathways in experimental acute afterload-induced right ventricular failure C Dewachter1, L Dewachter1, B Rondelet1, P Fesler2, S Brimioulle1, F Kerbaul3, R Naeije1 1 Faculty of Medicine, ULB, Brussels, Belgium; 2Lapeyronie Hospital, Montpellier, France; 3La Timone University Hospital, Marseille, France Critical Care 2010, 14(Suppl 1):P133 (doi: 10.1186/cc8365) Introduction The pathobiology of persistent right ventricular (RV) failure observed after an acute increase in pulmonary artery pressure (Ppa) remains incompletely understood. We hypothesized that these severe complications might be related to an activation of apoptotic pathways. Methods Fourteen anesthetized dogs were randomised to a transient 90 minutes pulmonary artery constriction or to a SHAM operation, followed 30 minutes later by hemodynamic measurements including efective arterial elastance (Ea) to estimate RV afterload and end-systolic elastance (Ees) to estimate RV contractility, and sampling of cardiac tissue to assess apoptosis by real-time quantitative polymerase chain reaction, enzyme-linked immunosorbent assay and immunohistochemistry. Results Transient increase in Ppa persistently increased Ea from 0.75 ± 0.08 to 1.37 ± 0.18 mmHg/ml, and decreased Ees from 1.06 ± 0.09 to 0.49 ± 0.09 mmHg/ml, Ees/Ea from 1.44 ± 0.06 to 0.34 ± 0.03 and cardiac output from 3.78 ± 0.16 to 1.46 ± 0.10 l/minute, indicating RV failure. As compared with the SHAM-operated group, and with left ventricular tissue in animals with persistent RV failure, there were decreased gene expressions of RV and septal Bcl-2, with no changes in the gene expressions of Bax and Bak, and an increase in the Bax/Bcl-2 ratio. RV and septal Bcl-XL, and RV Bcl-w gene expressions were decreased as compared with the SHAM-operated group. There were activations of RV caspases 8 and 9, and of RV and septal caspase 3. Difuse RV and septal apoptosis was conirmed by TUNEL staining. There were also increased RV and septal protein expressions of TNFα. Conclusions Acute afterload-induced persistent RV failure appears to be related to an early activation of apoptotic pathways, and to a myocardial increase of TNFα. P134 High incidence of severely prolonged QT interval after cardiac surgery M Biry, U Schurr, S Ritter, K Baenziger, A Zollinger, M Genoni Triemli City Hospital, Zurich, Switzerland Critical Care 2010, 14(Suppl 1):P134 (doi: 10.1186/cc8366) Introduction A prolonged QT interval may be associated with torsades de pointes and lead to sudden cardiac death. The aim of this study was to S47 determine both the frequency of QT prolongation and administration of QT prolonging drugs perioperatively in cardiac surgery. Methods This prospective observational study included 82 patients (mean age 67 years) undergoing elective cardiac surgery (coronary bypass grafting 37, valve surgery 29, combination 16). The QT interval was manually measured in lead II and V2 of a 12-lead electrocardiogram (ECG) and corrected for heart rate (corrected QT interval, QTc, calculated from Bazett’s formula) on the day before surgery, immediately after surgery, daily until day 5 and before hospital discharge. A QTc interval >440 ms in men and >460 ms in women in either ECG lead II or V2 was deined as moderately prolonged. A QTc interval >500 ms was considered to be moderately prolonged in patients showing complete left or right bundle block, and severely prolonged in patients without complete bundle block. All administered drugs that may prolong the QT interval were identiied and classiied according to the QTdrugs.org Advisory Board: drugs with a deinite risk of torsades de pointes (class 1, for example amiodarone, sotalol, haloperidol) or with a possible risk (class 2, for example granisetron, risperidone). Results A total of 489 ECG were analyzed (mean six ECG per patient). The QTc interval was moderately prolonged in 40/82 patients before surgery (48.8%). Five out of 40 patients (12.5%) had received drugs from class 1 preoperatively and 1/40 (2.5%) from class 2. The QTc interval was severely prolonged in 3/82 patients before surgery (3.7%), of which none had received QT prolonging drugs preoperatively. In 38/82 patients (46.3%) moderate QTc prolongation was newly discovered in at least one postoperative ECG. Seventeen put of 38 patients (44.7%) received drugs from class 1, and 3/38 (7.9%) from class 2 perioperatively. In 16/82 patients (19.5%) severe QTc prolongation newly appeared in at least one postoperative ECG. Seven out of 16 patients (43.8%) received drugs from class 1 and 1/16 (6.3%) from class 2 perioperatively. Conclusions Severe QT interval prolongation >500 ms occurs in onequarter of cardiac surgical patients in the perioperative period while moderate prolongation occurs in most of them. In nearly one-half of these cases, QT prolonging drugs like amiodarone and haloperidol may be involved. Before and during administration of such drugs in cardiac surgical patients perioperatively, assessment of the QT interval from routine ECG is recommended. P135 Endothelial protein C receptor expression after cardiopulmonary bypass in adult cardiac surgical patients R Hajek1, J Ruzickova2, L Slavik1, V Krcova1, M Simek1, I Fluger1 1 University Hospital Olomouc, Czech Republic; 2Hospital Prerov, Czech Republic Critical Care 2010, 14(Suppl 1):P135 (doi: 10.1186/cc8367) Introduction Endothelial protein C receptor (EPCR) is a transmembrane glycoprotein primarily localised on vessel endothelium. EPCR binds protein C (PC) on the endothelial surface and presents it to the thrombin/ thrombomodulin complex. Thrombin activates PC to APC, which exerts anticoagulant and anti-inlammatory efect. Proteolysis of membranebound EPCR releases soluble EPCR which can be detected in plasmatic circulation. This reaction indirectly correlates with thrombin generation and can be interpreted as marker of endothelial activation during cardiopulmonary bypass (CPB). Methods In a prospective study, the group of 35 adult patients (mean age 68 years) scheduled for cardiac surgery with standard cardiopulmonary bypass (duration 80 ± 30 minutes, heparin dose 3 mg/kg, mild hypothermia about 34°C) was evaluated. The markers of endothelial activation and coagulation parameters (EPCR, PAI-1, antithrombin, tPA, PTT, aPTT, ibrinogen, platelets and thromboelastography (TEG)) immediately before and after surgery were recorded. We hypothesized that the EPCR level (detected with ELISA monoclonal antibodies labeled with myeloperoxidase, 450 nm reader – detection limit 10 ng/ml soluble EPCR) increases after CPB and correlates with other markers of endothelial activation. Results The cut-of value of EPCR was set down 200 ng/ml. In 17% of patients the value above the cut-of (366 ng/ml before, 209 ng/ml after CPB) was detected. The EPCR value decreases after CPB (150.7 ± 124 vs 99.4 ± 70.6) whereas tPA increases (1.5 vs 9.3 ng/ml) and PAI-1 was unchangeable. A trend to hypocoagulation after CPB was noticed (Δibrinogen –1.04 g/l, Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 ΔaPTT +7.7 sec, Δplatelets –67 G/l) but no correlation between EPCR and TEG parameters (coagulation index ΔCI –1.46, ΔR +0.22 minutes, Δα΄ –3.9°, ΔMA –9.3 mm) was recorded. No correlation between EPCR and CPB duration was recorded as well. Conclusions CPB is not associated with increase of EPCR – a novel endothelial marker – measured immediately after operation. We need further studies to explain mechanisms of endothelial protection in this clinical setting. References 1. 2. 3. Esmon CT: The endothelial protein C receptor. Curr Opin Hematol 2006, 13:382-385. Thiyagarajan M, Cheng T, Zlokovic V: Endothelial cell protein C receptor: role beyond endothelium? Circ Res 2007, 100:155-157. Lopez-Sagasetza J, Montes R, Puy C, et al.: Binding of factor VIIa to the endothelial cell protein C receptor reduces its coagulant activity. J Thromb Haemost 2007, 5:1813-1816. P136 Urapidyl for hypertension control in severe pre-eclampsia: a comparative study with nicardipine R Vizitiu1, M Krauss-Grignard2, V Garcia1, L Valentin2, E Samain2, P Diemunsch1 1 Hôpitaux Universitaires de Strasbourg, France; 2Hôpital Saint Jacques, Besançon, France Critical Care 2010, 14(Suppl 1):P136 (doi: 10.1186/cc8368) Introduction During severe pre-eclampsia (PE), control of blood pressure (BP) is crucial in order to prevent systemic complications. Currently approved treatments such as nicardipine (N) and dihydralazine have drawbacks. Since hypertension in PE is associated with increased sympathetic activity, urapidil (U), a peripheral α1 antagonist, has potential for BP control in PE, but no controlled comparison of U with N is available. This preliminary randomized controlled trial aims to compare eicacy and safety of U and N to reduce BP in severe PE. Methods After IRB approval and signed informed consent, 18 women with severe PE without previous antihypertensive treatment were randomized to U or N groups. The therapeutic goal was to achieve a mean BP (MBP) between 105 and 125 mmHg. The U patients irst received U 6.25 mg boluses every 5 minutes until the diastolic BP dropped below 105 mmHg, followed by a 4 mg/hour infusion adjusted as needed. In the N group, patients irst received a N 1 γ/kg/minute infusion until a 15% reduction in mean BP, followed by a N 0.75 γ/kg/minute infusion adjusted as needed. Non-invasive BP was assessed every 5 minutes during treatment titration and then every 15 minutes. The time needed to reach the therapeutic goal was registered. The main endpoint was the achievement of the BP goal in 2 hours or less. Tolerance was assessed by the number of episodes of hypotension (HO) (deined as MBP below 100 mmHg) and side efects. Severe HO, deined as MBP below 80 mmHg or two episodes of HO, was considered as treatment failure and led to exclusion. Further assessment was limited to safety, amount of ocytocics used and neonatal evaluation by ICU paediatricians until discharge from ICU. Results were compared using analysis of variance. Side efects were compared with the chi-square test. Results One U patient was excluded from the eicacy assessment due to a protocol violation. The main endpoint was reached in all 17 patients, after 50 minutes in both groups. During the irst 2 hours, the needed treatment adjustment median value was 1 (0 to 10) in the U group and 1 (0 to 13) in the N group. Side efects attributable to the study treatment were observed in six of the nine cases in the N group and in one of the nine cases in the U group (P <0.02). There were no severe side efects or neonatal side efects. Conclusions No diference in eicacy could be shown in this preliminary series. Both treatments were easy to titrate. Fewer side efects were recorded in the U group. Further studies are needed in order to compare U and N. P137 Comparison of the efects of furosemide, captopril and lorazepam on noncomplicated hypertensive patients in the emergency department A Uzun, L Yamanel, O Cinar, H Hasman, B Comert Gulhane Military Medical Academy, Ankara, Turkey Critical Care 2010, 14(Suppl 1):P137 (doi: 10.1186/cc8369) Introduction Patients frequently refer to the emergency department with hypertension and related disorders. If hypertensive crisis is not diagnosed S48 in these patients, urgent treatment is not necessary. However, taking patient satisfaction into consideration, the emergency physicians usually discharge these patients after lowering the blood pressure with various medications [1]. This prospective, randomized, placebo-controlled study is designed in order to compare the efects of captopril, furosemide and lorazepam on lowering blood pressure and increasing patient satisfaction. Methods One hundred patients with uncomplicated hypertension were included in the study. All were randomized into four groups: (1) captopril group, (2) furosemide group, (3) lorazepam group, (4) placebo group. The blood pressure was measured at baseline, 30th, 60th and 90th minute. The patient satisfaction was assessed with a visual analog scale (VAS) at baseline and 90th minute. Results Captopril (23.64 mmHg), lorazepam (24.90 mmHg) and furosemide (24.10 mmHg) were found similarly efective in lowering blood pressure when we compare baseline and 90th minute, but all three drugs were superior to placebo (15.94 mmHg) (P <0.05) (Table 1). When patient satisfaction was assessed with the VAS, captopril (30.12 mm), furosemide (28.04 mm) and lorazepam (32.88 mm) were statistically similar and all three drugs were superior to placebo (22.76 mm). Table 1 (abstract P137). Mean arterial pressure Group MAP (mmHg) SD (mmHg) Level of signiicance Furosemide 24.1 10.7 19.9 to 28.5 Captopril 23.6 11.7 18.8 to 28.4 Lorazepam 24.9 10.1 20.7 to 29.1 Placebo 15.9 10.1 11.7 to 20.1 Total 22.1 11.1 19.9 to 24.3 Conclusions In conclusion, all three drugs can be used in subjects referred to the emergency department with uncomplicated hypertension. They are similarly efective in both lowering the blood pressure and increasing patient satisfaction. References 1. Chiang WK: Asymptomatic hypertension in the ED. Am J Emergency Med 1998, 16:701. P138 Incidence, risk factors and outcome of hypertensive crises in critically ill patients: a retrospective survey C Chelazzi, G Villa, V Selmi, AR De Gaudio University of Florence, Italy Critical Care 2010, 14(Suppl 1):P138 (doi: 10.1186/cc8370) Introduction Hypertensive crises (HC) are common among patients admitted to emergency rooms [1]. However, data are lacking about prevalence in the critically ill admitted to the ICU. The aim of the study was to assess the rate of HC in a cohort of patients admitted to a medical– surgical ICU, to look for risk factors for HC and to assess outcome of patients with HC. Methods Data have been collected from clinical charts of patients consecutively admitted to a mixed ICU (1 January 2008 to 31 January 2009). HC diagnosis was made based on JNC deinitions [2]. Patients were divided into two groups, the HC group and the control group. Diferences between groups were evaluated regarding age, gender distribution, admission diagnosis, SAPS II score, ICU length of stay, ICU mortality, and inhospital mortality (P <0.05). Clinical and behavioural conditions associated with HC were considered in the two groups and diferences tested for statistical signiicance (P <0.05). Results Of a total of 409 patients, 63 had one or more HC (15.4%). Conditions signiicantly associated with HC were age, cigarette smoking, cancer surgery, vasculopathy, medical indication to ICU admission, coronary artery disease, and chronic atrial ibrillation. HC patients showed higher ICU length of stay and ICU mortality. Conclusions HC were common among critically ill patients admitted to the ICU, irrespective of their admission diagnosis. Conditions strongly Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S49 associated with HC included cigarette smoking, cancer and age. HC were associated with worse outcomes. References 1. 2. Zampaglione B, Pascale C, Marchisio M, Cavallo-Perin P: Hypertensive urgencies and emergencies. Prevalence and clinical presentation. Hypertension 1996, 27:144-147. Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee: Seventh report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. Hypertension 2003, 42:1206-1252. P139 Comparative study to evaluate blood pressure levels measured by an invasive method versus a non-invasive method in patients in an intensive care unit S Kifer Macedo, T Bissoli, L Carvalho Dias, M Rodrigues Lacerda, R Paiva Barbosa de Castro, D Leite Cordeiro, R Janetti Carrara, PV Falcão Duarte Hospital Sao José do Avai, Itaperuna, Brazil Critical Care 2010, 14(Suppl 1):P139 (doi: 10.1186/cc8371) Introduction The blood pressure is an important variable in medical practice. A mistaken measurement can change the management of some diseases, modifying the patient’s prognosis. Therefore a correct deinition and control of blood pressure is an essential item in an ICU environment. Methods A prospective and comparative study of the blood pressure assessed by arterial catheterization (pressure referenced to atmospheric pressure at mid-chest level and adequate curve in the monitor) and by non-invasive blood pressure device (using the cuf of the monitor with automatic oscillometric measurement) in the upper and lower limbs. Results Included were 52 patients with average age of 54.7 years. In the right arm (RA), a diference between IBP and NIBP larger than or equal to 20 mmHg in systolic blood pressure (SBP) (plus or minus) occurred in 26.5% of the patients; 14.3% in diastolic blood pressure (DBP) and 8.7% in mean blood pressure (MBP). In the left arm (LA), 30.6% for SBP; 4.1% for DBP and 4.2% for MBP. In the left leg (LL), 40% for SBP, 17.8% for DBP and 17.8% for MBP. In the right leg (RL), 47.8% for SBP; 8.7% for DBP and 17.4% for MBP. Conclusions There were diferences between BP measured by invasive and non-invasive methods mainly in SBP. Lower limbs presented a larger diference, which means that non-invasive methods in this place are not reliable. The DBP in both methods presented less diference. References 1. Crit Care 2006, 10:R64. P140 Chronic atrial ibrillation in intensive care unit treated with electrical cardioversion: is it appropriate? M Murtigni1, E Mannelli1, D Colosimo1, S Cianferoni1, S Degl’innocenti2, J Parodo2, M Bonizzoli2, G Zagli2, A Peris2 1 Postgraduate School of Anesthesia and Intensive Care, University of Florence, Italy; 2Careggi Teaching Hospital, Florence, Italy Critical Care 2010, 14(Suppl 1):P140 (doi: 10.1186/cc8372) Introduction Chronic atrial ibrillation is known to be an important comorbidity factor in critically ill patients admitted to the ICU. The aim of this study was to evaluate whether electrical cardioversion in the ICU can reduce mortality of patients with chronic atrial ibrillation. Methods From January 2005 to November 2009, 50 patients with history of chronic atrial ibrillation admitted to the ICU were retrospectively studied. Patients were divided into two groups: the irst group included patients who underwent electrical cardioversion (CVE group, n = 10) and were discharged in sinus rhythm; the second included patients who did not undergo electrical cardioversion and were discharged with chronic atrial ibrillation (CAF group, n = 40). In both groups, mortality, antiarrhythmic drug therapy and oral anticoagulation regimen were monitored. The irst group’s follow-up evaluated maintenance of sinus rhythm. The number of Figure 1 (abstract P140). DC shocks required for the maintenance of sinus rhythm in patients of the CVE group was also collected. The main outcome parameter considered was 28-day mortality. Results Patients of both groups resulted in similar demographic and clinical parameters. In patients included in the CVE group, the maintenance of sinus rhythm was achieved with one DC shock in 66.6%, two DC shocks in 22.2% and three DC shocks in 11.1% of cases. The mortality rate at 24 hours was 0% while at 28 days was 11.1%, whereas patients in the CAF group had a 28-day mortality rate of 35%. See Figure 1. Conclusions Our pilot study indicates that the improvement of ventricular performance with the contribution of atrial systole might improve critically ill patients’ outcome. Considering the small number of cases, a prospective study, based on these preliminary results, is ongoing. P141 Applanation tonometry application in ICU patients with acute cardiogenic edema N Menestrina1, A Martini1, D Simion1, M Dan2, L Gottin1 1 University Hospital, Verona, Italy; 2Ospedale Civile, Verona, Italy Critical Care 2010, 14(Suppl 1):P141 (doi: 10.1186/cc8373) Introduction The incidence of acute cardiogenic pulmonary edema (ACPE) is increasing and it is now one of the leading causes of morbidity and mortality in our society. As the global population of European countries is getting older, the impact of arterial stifness is becoming more and more important in the pathophysiology of ACPE, besides coronary vascular disease and valvular disease. The aim of the study was to evaluate whether acute modiications in elastic artery distensibility can be involved in the pathogenesis of ACPE. Methods Six consecutive patients (four men and two women; age 76 ± 7.1 years) were admitted to our ICU with the clinical diagnosis of ACPE. All patients were studied with transthoracic echocardiography (TTE) and by evaluation of pulse wave analysis (PWA) and pulse wave velocity (PWV) with the applanation tonometry method, performed at admission and after clinical stabilization. Results In all patients, left ventricular systolic function was not signiicantly reduced when evaluated with transthoracic echocardiography, while a diastolic dysfunction was always demonstrated. We have recorded a signiicant (P <0.05) decrease in blood pressure values after clinical stabilization. Estimation of the central aortic pressure waveform by mathematical transformation of radial tonometry pressure was similarly reduced. Other tonometric parameters, such as the Augmentation Index, which represents the contribution of the wave relection to the global pulse pressure wave, and PWV, which is inversely correlated to the arterial compliance, were also signiicantly decreased, when compared with the values at the admission time. The subendocardial viability ratio (SEVR), an indirect index of myocardial perfusion relative to cardiac workload, increased after treatment with vasodilatators. Conclusions Our data conirm the determining role of the increased arterial stifness in the pathogenesis of ACPE, and how a therapeutic strategy able to ameliorate this target can be associated with a clinical improvement for the patient. The applanation tonometry could be an interesting method to evaluate these patients in the ICU setting. Reference 1. Nichols WN, O’Rourke MF: McDonalds Blood Flow in Arteries: Theoretical, Experimental and Clinical Principles. 4th edition. London: Hodder Arnold; 1998. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P142 A better prognosis for septic patients with left ventricular dysfunction? P Carrilho-Ferreira, A Pais-de-Lacerda, H Côrte-Real, C França Hospital de Santa Maria, Lisbon, Portugal Critical Care 2010, 14(Suppl 1):P142 (doi: 10.1186/cc8374) Introduction Several studies using angiographic or echocardiographic methods have shown that in septic shock (SSh) or severe sepsis (SeS), cardiac abnormalities, which are often documented [1], seem to have a relevant prognostic signiicance [2,3]. Methods A retrospective study was conduced during 6 months (April to September 2009) in an ICU of a university tertiary hospital, identifying all patients with SSh or SeS and reviewing their echocardiographic data. All the patients with known or clinical/echocardiographic evidence of signiicant prior cardiac disease were excluded from this analysis. Results Forty-nine patients were identiied with SSh or SeS from a total of 211 ICU patients (23.2%). Among these, 26 had echocardiograms done during their ICU stay (53.1%). We analyzed 19 echocardiograms from 15 patients. The remaining 11 patients were excluded, having ischemic heart disease (seven patients) and signiicant valvular heart disease (four patients). Within the SSh/SeS group of patients, those with echocardiograms were younger (mean age 56.3 vs 64.4) and more often women (53.3% vs 36.7%). The ICU mortality was nevertheless similar in the two groups (46.7% vs 46.9%). The primary sites of infection were the lungs and abdomen (26.7% each) or unknown (20%). The agents most frequently isolated were Gram-negative bacilli (26.7%). In 53.3% of cases there was no identiied agent. Echocardiographic evaluation revealed signiicant changes in 26.7% of the patients, with the remaining being considered normal. Of those with signiicant changes, 75% (n = 3) showed impairment of left ventricular (LV) systolic function with global hypokinesia simultaneously with diastolic dysfunction. Either abnormality was not found in any other patients. The mortality rate during ICU stay was lower in the group of patients with systolic and diastolic LV dysfunction compared with those with no apparent modiication of LV function (0 vs 58.3%). The right ventricle was dilated and showed high systolic pressures present in only one patient. Conclusions This study reinforces the concept that changes in systolic and diastolic functions are common in septic shock and severe septic patients, and that the development of these changes (as an adaptation mechanism) seems to correlate inversely with the acute mortality rate during ICU stay [2,4]. References 1. 2. 3. 4. Zanotti-Cavazzoni SL, et al.: Curr Opin Crit Care 2009, 15:392-397. Parker MM, et al.: Ann Intern Med 1984, 100:483-490. Poelaert J, et al.: Intensive Care Med 1997, 23:553-560. Jardin F, et al.: Chest 1999, 116:1354-1359. P143 Microvascular efects of pulsatile versus nonpulsatile perfusion during cardiopulmonary bypass PW Elbers1, J Wijbenga2, F Solinger2, A Yilmaz2, M Van Iterson2, E Van Dongen2, C Ince3 1 OLVG, Amsterdam, the Netherlands; 2St Antonius Hospital, Nieuwegein, the Netherlands; 3Academic Medical Center, Amsterdam, the Netherlands Critical Care 2010, 14(Suppl 1):P143 (doi: 10.1186/cc8375) Introduction While advantages of pulsatile perfusion (PP) during cardiopulmonary bypass (CPB) in terms of clinical outcome remain the subject of debate, possible beneits are generally thought to occur via improvements in microvascular low [1]. However, this is currently not supported by human clinical data. Therefore we used real-time human microvascular imaging to test our hypothesis that pulsatile perfusion would enhance microvascular perfusion. Methods We used sidestream dark ield imaging to record video clips of the human microcirculation in 16 patients undergoing routine CPB for cardiac surgery. Following administration of cardioplegia, CPB was continued in either pulsatile (PP, n = 8) or nonpulsatile (NP) mode. After 10 minutes, microvascular recordings were made. The perfusion mode was then switched from PP to NP or vice versa. Ten minutes later, a second series of microvascular video recordings were obtained. Global hemodynamic S50 and laboratory data were recorded and the energy equivalent pressure (EEP) and pulse pressure (both mean ± SD) were calculated to quantify PP generated surplus energy. Microvascular analysis was performed both for smaller and larger microvessels with a diameter cut-of of 20 μm. Assessments included perfused vessel density (PVD) (mean ± SD, 95% conidence intervals of the diference between NP and PP (95% CID)) and the Microvascular Flow Index (MFI) (mean ± SD and interquartile range). Results Pulsatile perfusion resulted in higher pulse pressure (27 ± 6 vs 7 ± 2 mmHg, P <0.0001) and CPB circuit EEP (184 ± 33 vs 150 ± 27 mmHg, P <0.0001) as compared with NP while MAP was similar between these perfusion modes (52 ± 11 vs 56 ± 13 mmHg, P = 0.09). Both for small and larger microvessels, we found no diferences in indices of microvascular perfusion between PP and NP. Small microvessel PVD was similar between PP and NP (6.65 ± 1.39 vs 6.83 ± 1.23/mm; 95% CID –0.50 to 0.87/mm, P = 0.58). The same was true for larger microvessel PVD (2.16 ± 0.64 vs 1.96 ± 0.48; 95% CID –0.50 to 0.11, P = 0.20). Similarly, the MFI did not difer between groups either for smaller (3.00 (2.83 to 3.00) vs 3.00 (2.75 to 3.0), P = 0.41) and larger microvessels (3.00 (2.75 to 3.00) 3.00 (3.00 to 3.00), P = 0.50). Conclusions PP during CPB does not alter human microvascular perfusion using standard equipment in routine cardiac surgery despite yielding higher CPB circuit energy equivalent pressure and patient pulse pressure. Reference 1. Murphy GS, et al.: Anesth Analg 2009, 108:1394. P144 Microcirculation and intravascular coagulopathy in patients with severe sepsis and septic shock R Wimmer, S Franz, S Siebelist, M Uschner, C Seidelmann, H Ebelt, S Hettwer, J Wilhelm, H Loppnow, K Werdan Universitätsklinikum Halle (Saale), Halle, Germany Critical Care 2010, 14(Suppl 1):P144 (doi: 10.1186/cc8376) Introduction Sidestream darkield imaging (SDF) technology is a new method to visualize directly microcirculation. In this study we examined the perfusion of the oral mucosa in patients with severe sepsis and septic shock in order to evaluate the link between the severity of illness, microcirculation and intravascular coagulopathy. Methods Microcirculation was analysed in 46 ICU patients with clinical suspicion for sepsis and procalcitonin >2 ng/ml. Microcirculation was recorded daily over a 7-day period (d0 to d6). Each day, at least ive single ilm clips were taken by SDF and analysed with special software on a PC. We used the functional vessel density and distribution of the vessel diameters as well-established parameters to qualify microcirculation. Laboratory parameters, hemodynamic data and vital signs were also registered. The degree of disseminated intravascular coagulopathy was evaluated by calculating the overt DIC score (according to ISTH), and severity of illness was determined using SAPS II and the SOFA score. Results During the stay in the ICU we observed a continuous descent of the DIC score (1.82 ± 1.91 on d0 vs 1.3 ± 1.94 on d6) as well as a decline of SAPS II (63.1 ± 14.1 on d0 vs 57.1 ± 18.4 on d6) and SOFA score (12.2 ± 3.9 on d0 vs 9.2 ± 5.8 on d6). The percentage of smallest vessels below 25 μm diameter decreased initially from 79.5 ± 21.9% (d1) to rise up then persistently 86.2 ± 10.3% (d6). Nonsurvivors (n = 11) had, compared with survivors (n = 35), a signiicantly higher initial DIC score on day 0 (1.3 ± 1.6 vs 2.05 ± 4.1; P <0.05). Conclusions Our data show a clear relation between the time courses of DIC and microcirculation in patients with severe sepsis and septic shock. This inding is in line with previous reports stating the profound impact of DIC on microcirculation and inally on patient outcome. P145 Prevalence and prognostic signiicance of cardiac abnormalities in the ICU: an echocardiographic study A Dell’Anna, C Sandroni, F Cavallaro, C Marano, M Antonelli UCSC School of Medicine, Rome, Italy Critical Care 2010, 14(Suppl 1):P145 (doi: 10.1186/cc8377) Introduction The aim was to describe the prevalence and type of cardiac abnormalities in ICU patients detected using echocardiography and to assess whether those abnormalities are correlated with ICU survival. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Methods Prospective cohort study. Consecutive patients hospitalized in the UCSC medical–surgical ICU for >24 hours were evaluated using transthoracic echocardiography (TTE). Patients admitted for postoperative monitoring or in an agonal state were excluded. Transesophageal echocardiography (TEE) was used when TTE was technically impossible. Measured parameters included: volume, thickness, global and regional kinesis of the left ventricle (LV), systolic function of the right ventricle (RV), and valvular function. Results From 1 March to 30 June 2009 a total of 100 patients (median age 68.5 years (IQR 50 to 77.5)) were included in the study. Medium SAPS II was 46 ± 15. ICU mortality rate was 29%. Median LOS in ICU was 14 days. TTE was technically feasible in 97 patients; the other three patients underwent TEE. Signiicant cardiac abnormalities were found in 66 patients, 41 of whom had no history of cardiac disease. The most frequent abnormalities were: tricuspidal regurgitation (45.3%), regional asynergies of LV (32%), left heart failure (30.2%) and mitral regurgitation (28%). The median left ventricular ejection fraction (EF) in our population was 50% (IQR 15 to 72%). Left ventricular end-diastolic volume was 100 ml (IQR 78 to 130 ml). Mean tricuspid annular systolic excursion (TAPSE) was lower in patients who died (18.9 vs 20.8 mm; P = 0.09). TAPSE was signiicantly correlated to EF (r coeicient = 0.48; P <0.0001). Pulmonary artery systolic pressure was signiicantly higher in patients who died than in those who survived to the ICU (49.8 ± 13.0 mmHg vs 35.0 ± 12.8 mmHg; P = 0.045). On logistic regression, prediction of ICU mortality was better (AUC = 0.901 vs 0.787) when cardiac abnormalities detected by echocardiography were added to a model based on age and SAPS II. Conclusions In our study, a complete echocardiographic assessment was possible using TTE in 97% of patients. Two-thirds of our population had echocardiographic abnormalities, 62.1% of whom were previously unknown. The presence of LV asynergies and reduced RV systolic function were associated with a worse prognosis. Detection of cardiac abnormalities increased prediction of ICU mortality based on logistic regression. S51 P147 Understanding vital-sign abnormalities in critical care patients S Hugueny1, DA Clifton1, M Hravnak2, MR Pinsky2, L Tarassenko1 1 University of Oxford, UK; 2University of Pittsburgh, PA, USA Critical Care 2010, 14(Suppl 1):P147 (doi: 10.1186/cc8379) Introduction We have previously shown how a data fusion index, based on the integration of vital signs continuously monitored in a stepdown unit (SDU), can identify the cardiorespiratory instability that often precedes adverse events [1]. We show how the correlations between vital signs, captured in a data fusion index based on a probabilistic model of normality [2], change during times of cardiorespiratory instability. Methods An observational study was carried out in a 24-bed SDU, in which vital signs from 326 patients were continuously recorded [1]. The existing standard of care used single-channel Medical Emergency Team (MET) activation criteria to determine when individual vital signs became abnormal. Retrospective evaluation of the continuous vital sign data identiied that MET criteria were exceeded on 238 nonartefactual occasions. One hundred and eleven of these were indicative of suicient cardiorespiratory instability that they should have required an MET call (critical events). Vital-sign dynamics during these events were compared with data from stable periods, using order statistics and covariance analysis. Results We found the probability distributions of the most extreme and the median data for each parameter over 1-minute intervals. The bivariate Gaussian distributions of best it for data from critical events (abnormal respiratory rate (RR) or heart rate (HR)) show signiicant diferences in covariance when compared with those calculated for data intervals from stable patients (see Figure 1, in which covariance is indicated by ellipse orientation). Under normal conditions (black ellipses), RR is correlated with HR. During critical events, tachycardia occurs with little or no variation in RR (red ellipses); tachypnoea occurs with little or no variation in HR (blue ellipses). P146 BNP and NT-proBNP in patients with acute myocardial infarction complicated by cardiogenic shock: results from the IABP Shock trial H Lemm1, R Prondzinsky1, A Geppert2, M Russ1, K Huber2, K Werdan1, M Buerke1 1 Martin-Luther-University Hospital, Halle, Germany; 2Wilhelminenspital, Vienna, Austria Critical Care 2010, 14(Suppl 1):P146 (doi: 10.1186/cc8378) Introduction B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) are routine diagnostic and monitoring markers in patients with heart failure. LV function and prognosis of these patients have been shown to be relected by BNP and NT-proBNP levels. However, in patients with cardiogenic shock after myocardial infarction, the relationship and relevance of these markers has not been elucidated. Methods The IABP Shock trial was as a monocentric, randomised and prospective clinical trial to determine the role of therapeutic intraaortic balloon pump (IABP) counterpulsation after primary percutaneous transluminal coronary angioplasty (PCI) in acute myocardial infarction (AMI) complicated by cardiogenic shock. Cardiac catheterization was performed in 40 patients within 12 hours of onset of hemodynamic instability. Creatinine, hemodynamic parameters and survival were determined. Further, BNP and NT-proBNP levels were measured on admission as well as 24, 48 and 72 hours afterwards. Results BNP levels detected diferences in treatment regarding LVunloading under IABP (632 ± 194 pg/ml vs 1,370 ± 475 pg/ml, P <0.05). However, there was no signiicant diference between the group treated with IABP and no IABP with regard to NT-proBNP levels. Interestingly, NTproBNP levels clearly diferentiated between survivors and nonsurvivors (4,590 ± 1,230 pg/ml vs 14,370 ± 4,886 pg/ml, P <0.05), contrary to no signiicant diference between survivors and nonsurvivors with regard to BNP levels (NS). Elevated levels of NT-proBNP in patients with cardiogenic shock might be more dependent on impaired renal function, which might relect additional organ dysfunction (creatinine >200 μmol/l vs creatinine ≤200 μmol/l: 24,965 ± 9,567 pg/ml vs 7,246 ± 2,650 pg/ml, P <0.05). Conclusions In myocardial infarction complicated by cardiogenic shock, levels of BNP and NT-proBNP both provide valuable additional information. BNP seems to closely relect the cardiac status and efects of therapy, while NT-pro-BNP seems a good indicator for prognosis in patients with cardiogenic shock by its dependency on organ dysfunction. Figure 1 (abstract P147). Conclusions Dynamics and correlations that exist in vital signs during periods of stability change signiicantly during periods of abnormality. A statistical approach that integrates vital signs and captures correlations between them will be sensitive to cardiorespiratory deterioration. References 1. 2. Hravnak M, et al.: Arch Intern Med 2008, 168:1300. Tarassenko et al.: Br J Anaesth 2006, 97:64. P148 Tissue microdialysis in critically ill septic patients: associations with sepsis severity and mortality M Theodorakopoulou1, S Orfanos1, A Diamantakis1, E Tsafou2, G Karkouli1, N Nikitas3, I Ikonomidis1, I Ilias1, I Tsangaris1, A Armaganidis1, I Dimopoulou1 1 Attikon University Hospital, Athens, Greece; 2Athens Veterans Hospital, Athens, Greece; 3Department of Therapeutics, Alexandra General Hospital, Athens, Greece Critical Care 2010, 14(Suppl 1):P148 (doi: 10.1186/cc8380) Introduction In vivo microdialysis (MD) is a bedside sampling method that permits continuous analysis of a patient’s extracellular tissue chemistry without consuming blood. MD is performed by implanting a commercially available catheter that mimics a blood capillary at the site of interest. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S52 Methods A total of 35 (20 men) mechanically ventilated septic patients having a median age of 60 years were studied. All patients met the ACCP/ SCCM consensus criteria for sepsis. Upon sepsis onset, a microdialysis catheter (CMA 60; CMA, Solna, Sweden) was inserted into the subcutaneous adipose tissue of the upper thigh. The dialysate samples were collected in microvials and were analyzed immediately for glucose, pyruvate, lactate, and glycerol using a mobile CMA ISCUS analyzer. The lactate/pyruvate (L/P) ratio was automatically calculated. Measurements were performed six times per day during the irst 6 days from sepsis onset. The daily mean values of MD measurements were calculated for each patient. Results Sepsis severity of the study group was graded as follows: sepsis (n = 5), severe sepsis (n = 2) and septic shock (n = 28). APACHE and SOFA scores at study entry were 23 ± 4 and 8 ± 3, respectively. Overall, 18 patients died yielding an ICU mortality rate of 51%. MD revealed that at study entry patients with septic shock had higher lactate (3.5 ± 1.6 vs 1.8 ± 0.9, P = 0.01), and higher pyruvate (204 ± 137 vs 95 ± 68, P = 0.04) levels compared with septic patients without shock. In contrast, the two groups had similar values for glucose (5.9 ± 2.7 vs 4.3 ± 2.9, P = 0.18), glycerol (369 ± 225 vs 252 ± 171, P = 0.21), and L/P ratio (83 ± 289 vs 75 ± 150, P = 0.92). Septic shock correlated with SOFA on day 1 (r = 0.55, P = 0.001), APACHE II (r = 0.42, P = 0.01), lactate on day 1 (r = 0.48, P = 0.004), lactate on day 2 (r = 0.50, P = 0.002), pyruvate on day 1 (r = 0.040, P = 0.018), and with pyruvate on day 2 (r = 0.35, P = 0.04). Nonsurvivors had higher glycerol (426 ± 236 vs 253 ± 157, P = 0.01) at study entry and on day 1 (437 ± 260 vs 282 ± 169, P = 0.04) compared with survivors. Nonsurvivors also had higher pyruvate levels on day 1 (170 ± 99 vs 104 ± 65, P = 0.03) and on day 2 (150 ± 81 vs 97 ± 61, P = 0.04). Logistic regression analysis showed that APACHE II (OR = 1.312, P = 0.06) and glycerol on day 1 (OR = 1.005, P = 0.04) independently predicted patient outcome. Conclusions MD seems to be a safe and promising tool in grading sepsis severity and in predicting early mortality in critically ill patients. P149 Delayed increase in inlammation and thenar VO2 in marathon runners A Lima1, J Weigel1, E Hoorn1, E Klijn1, R De Jonge1, N Morgenthaler2, U Haagen2, S Hofdom1, J Van Ochten1, C Ince1, J Bakker1 1 Erasmus MC University Medical Centre, Rotterdam, the Netherlands; 2 BRAHMS, Berlin, Germany Critical Care 2010, 14(Suppl 1):P149 (doi: 10.1186/cc8381) Introduction The muscle-speciic inlammatory response after strenuous exercise has some similarity with those observed in sepsis and it is used as a mirror of sepsis-speciic inlammatory response. Near-infrared spectroscopy (NIRS) has been used to quantify sepsis-induced metabolic alterations by measuring variations of tissue oxygen saturation (StO2) during a vascular occlusion test (VOT). We aimed to investigate whether NIRS dynamic variables could relect the magnitude of inlammatory process that follows strenuous exercise in marathon runners. Methods VOT-NIRS (InSpectra Model 650) measurement was performed before, at the inish line and on the day after the marathon in 13 runners (10 males/three females). VOT-derived NIRS traces were analyzed for StO2downslope (RdecStO2) and StO2-upslope (RincStO2). Blood samples were collected to measure C-reactive protein (CRP), procalcitonin (PCT), white blood cells (WBC), creatine kinase (CK), and lactate. Data are mean ± SD (in Table 1, median (IQR)). P <0.05 was considered statistically signiicant. Results The results of NIRS dynamic and hemodynamic variables are shown in Table 1. RdecStO2 was signiicantly increased in the day after the marathon. Signiicant increases in lactate (2.7 ± 0.5 vs 1.2 ± 0.3) and WBC Table 1 (abstract P149). NIRS and hemodynamic variables Baseline End line StO2 80 (8.0) 69 (8.0)* Day after 81 (7.0) RdecStO2 9.5 (7.0) 9.4 (9.0) 13 (7.0)* 4.0 (3.4) RincStO2 4.1 (3.0) 2.3 (3.0)* HR 58 (24) 87 (60)* 62 (26) MAP 93 (14) 88 (29) 87 (20) Data are median (IQR). *P <0.05. (14 x 103 ± 4 vs 5 x 103 ± 2) were observed after the completion of the marathon. Serum CRP, PCT and CK were signiicantly increased on the day after the marathon (0.6 ± 0.6 vs 12 ± 8; 0.09 ± 0.2 vs 0.7 ± 0.9; 398 ± 198 vs 1,932 ± 1,620), indicating the muscle-speciic inlammatory response as a result of muscle damage. Conclusions Delayed increase in thenar VO2 is associated with musclespeciic inlammatory response after strenuous exercise as a result of the muscle damage. P150 Value of peripheral tissue oxygen tension in animal experimental models of haemorrhagic and septic shock L Van Wagenberg, D Ramnarain, J Kesecioglu, L Leenen University Medical Centre Utrecht, the Netherlands Critical Care 2010, 14(Suppl 1):P150 (doi: 10.1186/cc8382) Introduction Current clinical parameters on eiciency of resuscitation are often insuicient, and unable to reliably assess tissue hypoxia. Considerable interest has been aimed to direct monitoring of tissue oxygen tension (ptO2). However, no golden standard has yet been found. Animal experimental models have shown interesting results in hypovolemic and septic shock and have lead to some interesting clinical studies. The purpose of this review is to evaluate the current value of ptO2 monitoring in animal experimental studies under various pathophysiological conditions. Methods An electronic literature search on Pubmed and Embase databases was conducted to ind relevant articles on tissue oxygenation and hemorrhage, trauma and endotoxemia. An initial amount of 7,876 articles were retrieved. After applying inclusion and exclusion criteria and critical appraisal, 48 articles were ranked on their level of evidence. Results After screening of the 48 articles, 19 articles were found to be suitable to answer our goal. Ten articles discussed tissue oxygenation in a hemorrhagic model and nine articles in a model of endotoxemia. No relevant articles concerning ptO2 and experimental trauma were found. Eight articles compared splanchnic ptO2 measurements in relation to ptO2 measured in several peripheral sites, like subcutaneous and skeletal muscle tissue. A positive correlation between these locations was found in seven articles. A decrease in both peripheral and central tissue oxygen pressure (ptO2) was found during hemorrhage. Importantly, peripheral ptO2 changed earlier during hemorrhage before any hemodynamic parameter did. In contrast, only one article found an earlier change in hemodynamic parameters than in peripheral ptO2. Nine articles discussed ptO2 in a model of septic shock. Only two studies compared peripheral ptO2 measurements with splanchnic ptO2 measurements. Both sites had decreased ptO2 values in endotoxemia and both were found to change before any changes in hemodynamic parameters. Conclusions A signiicant relation between intestinal ptO2 and peripheral ptO2 was found in studies on experimental models of hemorrhagic and septic shock. This suggests that peripheral sites like the subcutaneous tissue or skeletal muscles tissue are reliable locations for measurements of ptO2. P151 Incidence of a low tissue oxygen saturation in a mixed population of critically ill patients A Veening1, C Ince2, J Bakker2 1 Hutchinson Technology Inc., Rotterdam, the Netherlands; 2Erasmus MC University Medical Center, Rotterdam, the Netherlands Critical Care 2010, 14(Suppl 1):P151 (doi: 10.1186/cc8383) Introduction Tissue oxygen saturation (StO2; normal value 87 ± 6% [1]) measured with NIRS has been associated with disease severity in trauma [1]. The incidence of StO2 <75% that has been associated with organ failure [2] and its clinical consequences for ICU patients are unknown. Methods StO2 was measured on the thenar eminence (InSpectra StO2 Monitor Model 650; Hutchinson Technology) of all patients present in the ICU during 1 week. All patients were measured only once (on Monday when already admitted, or on the day of admission). Data are presented as mean ± SD unless otherwise speciied. Results Forty-one patients (age 53 ± 19 years; 63% males) were included. Fifty-nine percent of the patients were admitted following surgery. Median Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S53 Figure 1 (abstract P152). Figure 1 (abstract P151). Frequency distribution of StO2. Figure 2 (abstract P151). Day of admission at time of measurement vs StO2. StO2 was 83% (IQR: 75 to 88) (Figure 1). No relationship was found between day of admission and measured StO2 (Figure 2). Thirty-one patients (76%) had StO2 below normal (Figure 2, top line). Twelve (29%) patients had StO2 ≤75% (Figure 2, dotted line). Seven patients had StO2 <70; mortality of these patients was 29% vs 9% in patients with StO2 >70% (NS). Conclusions The incidence of an abnormal StO2 in critically ill patients is high. Also very low StO2 values are frequently found and may be associated with increased mortality. References 1. 2. J Trauma 2005, 58:806-813. J Trauma 2007, 62:44-54. P152 Use of near-infrared spectroscopy during a vascular occlusion test to assess the microcirculatory response during luid responsiveness E Futier1, B Vallet2, E Robin2, M Vignaud1, J Constantin1, J Bazin1 1 University Hospital of Clermont-Ferrand, France; 2University Hospital of Lille, France Critical Care 2010, 14(Suppl 1):P152 (doi: 10.1186/cc8384) Introduction Adequate volume expansion for hypovolemia should improve cardiac preload and stroke volume leading to improved microvascular blood low, tissue perfusion and oxygenation. The dynamic recovery slope of tissue oxygen saturation (StO2) during a standardized vascular occlusion test (VOT) is proposed to relect microvascular reactivity. We aimed at evaluating the dynamic StO2 variations during luid challenge in high-risk surgical patients. Methods Thirteen adult Caucasian patients, ASA II to III, undergoing major abdominal surgery, were included. In all, cardiac output (CO), stroke volume (SV), pulse pressure variation (PPV), and standard hemodynamic parameters were continuously recorded. Fluid responsiveness was deined as an increase in SV >15%, after a 500 ml colloid (HEA 130/0.4) infusion over 10 minutes. StO2 measurements and VOT (sphygmomanometer inlated until >50 mmHg above systolic pressure and kept inlated until StO2 decreased to 40%) were performed after anaesthesia induction (baseline), and before (PPV >13%, therefore deining hypovolemia) and after luid challenge. Results At baseline, no patient was preload dependent (mean PPV 7.9 ± 2%), and none required vasopressors during the procedure. Baseline mean StO2 was 85 ± 6%, while CO and SV were 4.9 ± 0.9 l/minute and 68 ± 21 ml, respectively. During hypovolemia, compared with baseline, there was no diference in both StO2 (85 ± 6 to 84 ± 9%, P = 0.76) and StO2 desaturation rate (–9.6 ± 1.6 to –11 ± 2.7%/minute, P = 0.10), while the StO2 recovery slope was lowered (5.1 ± 1.6 to 3.8 ± 1.5%/second, P = 0.04). Patients were all responders to luid challenge. After volume expansion, SV (84 ± 20 vs 62 ± 12 ml, P <0.01) and CO (6.5 ± 2 vs 4.8 ± 1.2 l/minute, P <0.01) were higher, with no signiicant changes in both StO2 and StO2 desaturation rate. Fluid challenge induced a 46% increase in StO2 recovery slope (P <0.01; Figure 1), which was comparable with baseline. Conclusions Whilst redistribution of blood low may occur during circulatory failure (vasoconstriction of lesser vital organs), impairment of microcirculation and tissue hypoperfusion indicators are of particular importance. Both hypovolemia and intravascular volume expansion are associated with signiicant modiications in the dynamic recovery slope of StO2. Future studies are needed to better clarify its potential clinical applications. P153 Inluence of mechanical ventilation on intestinal microcirculation and inlammation in septic rats D Henzler1, M Haeusler1, O Gil1, R Chankalal2, N Ismaiel2, C Lehmann2 1 QEII Health Sciences Center, Halifax, Canada; 2Dalhousie University, Halifax, Canada Critical Care 2010, 14(Suppl 1):P153 (doi: 10.1186/cc8385) Introduction Although the adverse efects of mechanical ventilation on circulation and intestinal organ perfusion are well known, the inluence of assisted breathing versus controlled ventilation has not been investigated. We hypothesized that pressure support ventilation causes less decrease in gut perfusion and less neutrophil adhesion than controlled ventilation. Methods Male SD rats (n = 40) were anesthetized and tracheotomized and 10 animals each ventilated in pressure support (PSV) or pressure controlled (PCV) mode. PCV animals were paralyzed. After 5 hours of ventilation, intravital microscopy was performed. Endotoxin (15 mg/kg lipopolysaccharide) was given to 20 rats, 20 animals served as controls. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Results There were no diferences in baseline hemodynamics or gas exchange. Animals were stable over the whole observation period with minimal changes in blood pressure and oxygenation. In PCV, the percentage of functional capillaries in the longitudinal mucosal layer was lower (57 ± 39%) than in PSV (87 ± 33%). In sepsis, there was a further decrease in PCV and a major decrease in PSV. Leukocyte adhesion in the intestinal submocosal venules (for example, V1 venules) was higher in PCV (228 ± 119) than in PSV (93 ± 65) in controls, but not in septic animals. Conclusions In septic rats with preserved macrohemodynamic stability, intestinal perfusion was impaired after LPS infusion. Pressure-controlled ventilation had a signiicant inluence on microcirculation and neutrophil adhesion in controls. In septic animals, pressure support ventilation did not attenuate these adverse efects as compared with PCV. P154 ScvO2 and Pcv-aCO2 as complementary tools for goal-directed therapy during high-risk surgery E Futier1, B Vallet2, E Robin2, J Constantin1, J Bazin1 1 University Hospital of Clermont-Ferrand, France; 2University Hospital of Lille, France Critical Care 2010, 14(Suppl 1):P154 (doi: 10.1186/cc8386) Introduction Central venous oxygen saturation (ScvO2) has been shown to be a useful therapeutic target in septic shock or high-risk surgery. The central venous-to-arterial carbon dioxide diference (Pcv-aCO2) has been proposed as a complementary tool for goal-directed therapy (GDT) in septic shock. We tested the hypothesis that both ScvO2 and Pcv-aCO2 could be used as complementary tools for GDT during high-risk surgery. Methods Seventy adult patients, ASA I to III, undergoing major abdominal surgery, were randomly assigned to 6 ml/kg/hour (R-GDT group, n = 36) or 12 ml/kg/hour (C-GDT group, n = 34) of crystalloids. Additional boluses of HES (130/0.4) were given to maintain respiratory variation in peak aortic low velocity (ΔPV) below 13%. In both groups, ScvO2, cardiac output (CO), oxygen delivery (DO2i), Pcv-aCO2 and postoperative complications were blindly recorded. Results At baseline, there were no diferences in hemodynamic variables, ScvO2 (79 ± 7 vs 80 ± 6, P = 0.37) and Pcv-aCO2 (6 ± 3 vs 6 ± 2, P = 0.95). The total volume of luid perfused was larger in the C-GDT group than in the R-GDT group (P <0.01). The two groups showed no diferences in intraoperative blood loss, blood transfusion, mean CO and mean DO2i values. Overall, postoperative complications were increased in the R-GDT group (P <0.01), especially postoperative sepsis occurred more often (P = 0.0064). Minimal ScvO2 (minScvO2) was higher in the C-GDT group (72 ± 6 vs 69 ± 6%, P = 0.04). In patients with complications, minScvO2 was signiicantly reduced (72 ± 6 vs 67 ± 6%, P = 0.0017). minScvO2 <70% was independently associated with sepsis (OR 4.2 (95% CI 1.1 to 14.4), P = 0.025). Intraoperative mean Pcv-aCO2 was higher in the R-GDT group (7 ± 3 vs 5 ± 2 mmHg, P <0.01). In patients who develop sepsis, Pcv-aCO2 was higher than in patients who did not (8 ± 2 vs 5 ± 2 mmHg, P <0.01). In patients with ScvO2 >70% and who develop sepsis, Pcv-aCO2 was also signiicantly higher (P <0.01). The area under the ROC curve was 0.758 (95% CI 0.71 to 0.81) for discrimination of patients with ScvO2 >70% who did and did not develop sepsis, with 5 mmHg as the best threshold value. Conclusions ScvO2 relects important changes in oxygen delivery in relation to oxygen needs during the perioperative period and might help guiding GDT better than ΔPV alone. Pcv-aCO2 appears a useful tool to identify persistent hypoperfusion when GDT is associated with ScvO2 >70%. P155 Prognostic value of central venous–arterial pCO2 diference in severe sepsis and septic shock patients F Machado, A Guarnieri, FG Freitas, M Assuncao, B Mazza, M Jackiu Federal University of São Paulo, Brazil Critical Care 2010, 14(Suppl 1):P155 (doi: 10.1186/cc8387) Introduction Global indices of tissue perfusion include lactate and central venous oxygen saturation (SvcO2). The mixed venous–arterial pCO2 diference (ΔCO2m) cannot serve as a marker of tissue hypoxia. It S54 is a marker of venous low adequacy to remove the total CO2 produced by peripheral tissues [1]. Substitution of a central for a mixed venous– arterial pCO2 diference is acceptable [2]. The objective was to assess the relationship between ΔCO2 and SOFA score variation in patients with severe sepsis and septic shock. Lactate and ScO2 were also evaluated. Methods Prospective observational study in patients with severe sepsis and septic shock admitted to an adult tertiary ICU. The management of sepsis was carried out as proposed by Surviving Sepsis Campaign guidelines. The earliest simultaneous measurement of lactate, SvcO2, and ΔCO2 were obtained when clinically indicated (T0) and after 8 to 12 hours (T8-12). The SOFA score was determined at T0 and after 24 hours (T24) and ΔSOFA (T24-T0) was calculated. The patients were classiied according to their parameters at T0 (ΔCO2 ≥6 vs <6, lactate ≥28 mg/dl vs <28 mg/dl, SvcO2 ≥70% vs <70%) and their trends after 8 to 12 hours (adequate vs not adequate). Those groups were compared regarding their ΔSOFA score. The Student’s t test was used for analysis and results were considered signiicant if P <0.05. Results Forty-three patients were included with mean of 60.2 ± 18.6 years, time from intensive care admission to T0 10.3 ± 9.3 hours and duration of organ dysfunction before enrollment 21.4 ± 15.6 hours. APACHE II, SOFA T0, and SOFA T24 scores were 18.8 ± 6.5, 7.9 ± 3.8, and 8.0 ± 4.3, respectively. ΔCO2 at T0 (P = 0.60) and its trend (P = 0.36) are not related to ΔSOFA. The analysis of SvcO2 also showed no signiicant inding. Patients with high (≥28 mg/dl) blood lactate concentration at T0 (P = 0.03) and not adequate in blood lactate concentration at T8-12 (P = 0.04) had an increase in SOFA score. Conclusions Patients with hyperlactatemia in the beginning of admission, which persists with increased levels of lactate, evolve to a worsening of SOFA score in 24 hours. ΔCO2 and SvcO2 and its trends are unrelated to the SOFA score in 24 hours. References 1. 2. Lamia B, et al.: Minerva Anestesiol 2006, 72:597-604. Cuschieri J, et al.: Intensive Care Med 2005, 31:818-822. P156 Veno-arterial carbon dioxide gradient at the early stage of septic shock J Mallat, P Salaun, G Gasan, L Tronchon, D Thevenin Hospital of Lens, France Critical Care 2010, 14(Suppl 1):P156 (doi: 10.1186/cc8388) Introduction The measurement of cardiac output and its adequacy to tissue needs are essential for hemodynamic evaluation. In a recent review it was stated that the venous-to-arterial carbon dioxide diference (dPCO2) could be considered a marker of adequacy of venous blood low to remove the total CO2 produced by the peripheral tissues. Several studies have already shown that dPCO2 and the cardiac index (CI) are inversely correlated in critically ill patients. However, the dPCO2 can be inluenced not only by CI, but also by other factors governing CO2 production and CO2 elimination. The aim of this work was to study the behaviour of dPCO2, measured from central venous blood, and its evolution during the early stage of septic shock. Methods Forty-six patients with septic shock were prospectively included. dPCO2 was calculated by the diference between the arterial PCO2 and the PCO2 from central venous blood. A value of dPCO2 >6 mmHg was considered high. The CI was measured by transpulmonary thermodilution. ScvO2 and serum lactate were obtained. Patients were separated into a normal dPCO2 group and a high dPCO2 group. The results were compared by Student t test or Mann–Whitney test. P <0.05 was chosen as signiicance. Results At inclusion 24 patients (52%) had a high dPCO2. These patients had a lower CI (3.5 ± 1.1 vs 4.2 ± 0.99 l/min/m2, P = 0.04) and lower ScvO2 (57 ± 17 vs 71 ± 8%, P <0.001) than patients with normal dPCO2. No diference was found in PaCO2 or PaO2/FiO2 levels between both groups, suggesting a similar CO2 elimination. Thirteen patients had a decrease in dPCO2 from above to below 6 mmHg (from 8 ± 2 to 5 ± 1 mmHg, P = 0.001) associated with an increase in CI (from 3.7 ± 1.3 to 4.2 ± 1.3 l/min/ m2, P = 0.003). Conversely, 11 patients had an increase in dPCO2 from below to above 6 mmHg (from 3.8 ± 2.4 to 7.7 ± 2.6 mmHg, P = 0.002). In these patients, CI decreased (from 4.3 ± 1.3 to 3.5 ± 1 l/min/m2, P = 0.013) equally. A negative correlation was established between dPCO2 and CI (r2 = 0.40, P <0.001) and between changes in dPCO2 and change in CI Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 (r2 = 0.16, P = 0.008) during the study. The lactate level was similar in both groups. The ScvO2 was correlated with CI (r2 = 0.44, P <0.001). Conclusions dPCO2 patients with septic shock seem to be related principally to CI. dPCO2 might be a marker of tissue perfusion adequacy to patient’s metabolism and could be a resuscitation target for management of septic shock patients. P157 Venous–arterial PCO2 diference as an early predictor of organ dysfunction in the ICU E Biagioni, E Boni, M Girardis Azienda Ospedaliera Universitaria Policlinico di Modena, Italy Critical Care 2010, 14(Suppl 1):P157 (doi: 10.1186/cc8389) Introduction The early identiication and scrupulous monitoring of tissue dysoxia can improve the management of critical patient. In this light, the inal product of aerobe and anaerobe metabolism (that is, carbon dioxide) can provide useful information on adequacy of tissue perfusion and metabolism [1,2]. The aim of our study was to evaluate whether the venous–arterial PCO2 gradient provides useful information on tissue dysfunction in patients admitted to the ICU. Methods We retrospectively studied 135 patients admitted to our ICU in 2006 with a length of stay >24 hours and a gas analysis from arterial and central venous blood at admission. Venous–arterial PCO2 gradient (ΔpCO2), organ dysfunction in the irst 24 hours and ICU mortality were collected. Organ dysfunction was deined as a SOFA score ≥2 for each organ. The patients were subdivided and compared on the basis of ΔpCO2 value: ΔpCO2 ≥ 6 mmHg (High group) and ΔpCO2 <6 mmHg (Normal group). Results Thirty-nine patients (29%) showed a ΔpCO2 ≥ 6 mmHg (ΔpCO2 9.6 ± 3.1). In the Normal group the mean ΔpCO2 value was 1.2 ± 4.1. The High group showed a larger rate (44%) of respiratory failure than the Normal group (25%) Similarly, cardiovascular dysfunction was observed in 49% of the patients of the High group and only in 19% of the Normal group (P <0.05). Renal failure was also slightly larger in the High group (31%) than in the Normal group (22%) (P >0.05). As expected, patients of the High group showed an ICU mortality (33%) three times larger (P <0.05) than patients of the Normal group (12%). Conclusions The above data support the hypothesis that ΔpCO2 can provide useful information on the tissue perfusion and metabolism in ICU patients and can be used as a reliable biomarker for early prediction of organ dysfunction. References 1. 2. Mekontso A, Castelain V, Anguel N, et al.: Combination of venoarterial PCO2 diference with arteriovenous O2 content diference to detect anaerobic metabolism in patients. Intensive Care Med 2002, 28:272-277. Lamia B, Monnet X, Teboul L: Meaning of arterio-venous PCO2 diference in circulatory shock. Minerva Anestesiol 2006, 72:597-604. P158 Lactate and ScvO2 combinations do not predict mortality in ICU patients A Ali, S Gearay, D Bennett, M Terblanche St Thomas’s Hospital, London, UK Critical Care 2010, 14(Suppl 1):P158 (doi: 10.1186/cc8390) Introduction Lactate (LCT) is used to identify critically ill patients at risk of death. Low central venous oxygen saturation (SvO2) is also associated with increased mortality. It is physiologically plausible that patients with low SvO2 and high LCT do worse versus those with only one of SvO2 or LCT abnormal, or with both normal. However, the prognostic value of combining LCT and SvO2 is unknown. We studied the association between ICU mortality and combinations of SvO2 and LCT abnormality. Methods We used a retrospective single-centre cohort methodology using data obtained from the comprehensive electronic clinical information system (CareVue™). All patients who underwent LCT and SvO2 measurement (from internal jugular or subclavian vein) during the irst 24 hours after ICU admission (2004 to 2009) were included. Baseline (demographic, physiological), daily follow-up (physiological, SOFA) and 30-day mortality data were recorded. Worst admission values were used to combine SvO2/LCT into four groups (SL groups: 0 to 3) dichotomised by S55 mean (SvO2) and median (LCT): 0 – N/N; 1 – L/N; 2 – N/H; 3 – L/H. Descriptive analysis used standard statistical techniques. Variables individually associated (P <0.20) with SvO2 and/or LCT, and mortality were included in a multivariate logistic regression model (with mortality as the dependent variable) using forward stepwise inclusion. Variables with adjusted P <0.05 remained in the inal model. Results A total of 1,544 patients were included. Mean (SD) SvO2 was 63.6 (11.3) and median (IQR) LCT 3.85 (4.3). Overall mortality was 20.2%. Univariate analysis showed a statistically signiicant association between SL group and mortality (P <0.001). This association did not remain signiicant in multivariate analysis: only LCT (not SvO2) was associated with mortality when adjusted for other variables. Conclusions In this population LCT but not SvO2 predicts 30-day ICU mortality. These data does not support the hypothesis that patients with low SvO2 and high LCT do worse compared with when only one of SvO2 or LCT is abnormal, or if both are normal. P159 Early changes in lactate and central venous saturation combinations do not predict subsequent changes in organ performance A Ali, S Gearay, D Bennett, M Terblanche St Thomas’ Hospital, London, UK Critical Care 2010, 14(Suppl 1):P159 (doi: 10.1186/cc8391) Introduction High lactate (LCT) identiies critically ill patients, predicts risk of mortality and guides resuscitation. Low central venous oxygen saturation (SvO2) is associated with mortality and is used as a resuscitation target. A change in LCT, but not in SvO2, has been shown to relate to outcome. It is physiologically plausible that those with low SvO2 and high LCT do worse versus those with only one of SvO2 or LCT abnormal, or with both normal. Early changes in these combinations may also determine subsequent changes in organ performance. We hypothesised that changes in combinations in SvO2 and LCT from day 1 to day 2 predicted changes in total SOFA between day 2 and day 4. Methods We used a retrospective cohort methodology using data obtained from the electronic clinical information system. All included patients underwent LCT and SvO2 measurement (from internal jugular or subclavian vein) in the ist 24 hours after ICU admission. Baseline (demographic, physiological), daily follow-up (physiological, SOFA) and 30-day mortality data were recorded. Worst admission values were used to combine SvO2/LCT into four groups (SL groups: 0 to 3) dichotomised by mean (SvO2) and median (LCT): 0 – N/N; 1 – L/N; 2 – N/H; 3 – L/H. Variables individually associated (P <0.20) with a change in total SOFA between day 2 and day 4 were included in a multivariate linear regression model (with change in total SOFA as the dependent variable) using forward stepwise inclusion. Variables with adjusted P <0.05 remained in the inal model. Results A total of 1,544 patients were included. Complete data on all change variables were available for 675 patients. Mean (SD) SvO2 was 63.6 (11.3) and median (IQR) LCT 3.85 (4.3). Mean (SD) APACHE II and age were 22.4 (6.2) and 64.9 (15.9), respectively, and 61.9% were male. The mean fall (SD) in total SOFA from day 2 to day 4 was 1.05 (2.78). APACHE II (adj. P <0.001), day 1 SL group (adj. P = 0.019) and SOFA (adj. P <0.001), and C-reactive protein >209 mg/l (adj. P = 0.006) were independently associated with Δ-SOFA. Changes in SL group were not associated with improvements in organ function (adj. P = 0.12). Conclusions APACHE II, SL group and total SOFA (both on day 1) and C-reactive protein >209 mg/l were associated with worsening organ function between day 2 and day 4. Improvement in combinations of SvO2 and LCT were not associated with changes in organ performance. P160 Regional lactate and oxygen saturation gradients: preliminary experimental data A Pereira, P Rehder, C Dias, L Poli de Fugueiredo, E Silva Universidade de São Paulo, Brazil Critical Care 2010, 14(Suppl 1):P160 (doi: 10.1186/cc8392) Introduction Regional diferences among blood low and oxygen uptake are widely cited but not well explained. The lactate shuttle Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S56 Figure 1 (abstract P160). Oxygen saturation gradients – heart and lung. concept, alternative sets of lactate production, nowadays, challenges our comprehension about oxygen delivery and consumption. Recent studies have shown the prognostic value of oxygen and lactate gradients measured from central venous to pulmonary artery circulation. Our data represent one sample of our 4-year experimental research, trying to build a conceptual framework related to oxygen and lactate dynamic in diferent hypoxic states. Methods Sixteen large white pigs (35 kg) and seven shams were studied. After anesthesia and full monitorization (EKG, MAP, etCO2, continuous gas analysis, Doppler portal low, small bowel tonometry, liver tpO2 and urine output), abdominal sepsis was induced by fecal peritonitis. Results See Figures 1 and 2. Conclusions Our preliminary data show high rates of oxygen extraction rates in coronary circulation and suggest apparent lactate consumption by heart and lactate production by the lung, during experimental sepsis. P161 Examination of the utility of serum lactate and base deicit in hemorrhagic shock K Jonishi1, Y Sakamoto1, Y Ueno2, H Matsumoto1, Y Hara1, N Kutsukata1, K Mashiko1, H Yokota3 1 Chiba Hokusoh Hospital, Nippon Medical School, Chiba, Japan; 2Tsukuba Medical Center, Ibaraki, Japan; 3Nippon Medical School, Tokyo, Japan Critical Care 2010, 14(Suppl 1):P161 (doi: 10.1186/cc8393) Introduction Serum lactate and base deicit are markers of tissue ischemia and are used to assess the adequacy of resuscitation. Recent reports have shown that they are also useful markers associated with the severity and prognosis of sepsis and trauma; however, there are few reports regarding their use in hemorrhagic shock. We examined the utility of serum lactate and base deicit about the patients with upper gastrointestinal hemorrhagic shock. We thought that upper gastrointestinal hemorrhage cases relected hemorrhagic clinical conditions of hemorrhagic shock rather than trauma. Methods We retrospectively reviewed the cases of 152 consecutive patients with upper gastrointestinal hemorrhage and analyzed the relationships Figure 2 (abstract P160). Lactate gradients – heart and lung. between levels of serum lactate, base deicit and hemorrhagic shock on admission. We divided the patients into two groups according to whether their shock index (systolic blood pressure/pulse) was less than 1 (shock group, n = 57; 37.5%) or greater than 1 (nonshock group, n = 95; 62.5%). Results Among the 152 patients included in the analysis, 97 had gastric ulcers, 18 had esophageal varices, 17 had duodenal ulcers, seven had acute gastric mucosal lesions, six had gastric carcinoma, ive had Mallory– Weiss syndrome, and two had gastric varices. The study cohort comprised 27% women (n = 41) and 73% men (n = 111). The median age was 62.2 ± 15.1 years. On admission, the average serum lactate level was 3.4 ± 4.2 mmol/l, and the base deicit was –2.4 ± 5.1 mmol/l. The serum lactate level and base deicit were signiicantly higher in the shock group than in the nonshock group (5.8 ± 5.5 vs 2.0 ± 2.4 mmol/l, P <0.001, and –4.4 ± 5.8 vs –1.0 ± 4.1 mmol/l, P = 0.002, respectively). Conclusions We observed a relationship between serum lactate level, base deicit value and hemorrhagic shock in patients with upper gastrointestinal hemorrhage. References 1. 2. Mikkelsen ME, et al.:Crit Care Med 2009, 37:1670-1677. Smith I, et al.: Intensive Care Med 2001, 27:74-83. P162 Metformin increases platelet lactate production by inhibiting mitochondrial function A Protti1, A Lecchi1, F Fortunato1, F Rosini1, A Artoni1, N Greppi1, A Gjoka1, G Mistraletti2, G Comi1, L Gattinoni1 1 Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Università degli Studi, Milan, Italy; 2Ospedale San Paolo, Università degli Studi, Milan, Italy Critical Care 2010, 14(Suppl 1):P162 (doi: 10.1186/cc8394) Introduction Metformin improves glucose control by inhibiting hepatocyte mitochondrial complex I [1]. The pathogenesis of metforminassociated lactic acidosis is poorly understood and whether drug accumulation per se can cause hyperlactatemia remains unclear. The aim Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S57 Table 1 (abstract P162) Lactate (mM) FL2/FL1 Complex I (nM/minute/mg) CS (nM/minute/mg) No metformin Metformin 0.01 mM Metformin 1 mM Metformin 100 mM P value 5±1 5.6 ± 1.5 6.8 ± 2.5 102 ± 27 5±1 4.6 ± 1.1 6.8 ± 2.3 94 ± 15 10 ± 2 4.6 ± 0.7 4.0 ± 1.6 99 ± 20 21 ± 4 1.8 ± 0.7 1.6 ± 1.4 105 ± 10 <0.001 <0.001 <0.001 0.74 PRP was incubated with metformin at the reported inal concentrations (n = 4). of the present study is to clarify whether metformin can increase cellular lactate production by inhibiting mitochondrial function in tissues other than the liver. Methods Platelet-rich-plasma (PRP) from healthy volunteers was incubated for 72 hours with diferent doses of metformin. The plasma lactate concentration was then measured. The proportion of normally polarized vs abnormally depolarized platelet mitochondria (FL2/FL1) was assessed by low cytometry after staining with JC-1. Platelet respiratory chain complex I activity and citrate synthase (CS) activity, a marker of mitochondrial content, were measured by spectrophotometry. Data are presented as means ± SD. Analysis was performed with one-way ANOVA. Results Main results are reported in Table 1. Conclusions Metformin can cause hyperlactatemia by impairing platelet mitochondrial function. Reference 1. El-Mir MY, Nogueira V, Fontaine E, Avéret N, Rigoulet M, Leverve X: J Biol Chem 2000, 275:223-228. P163 Artifactual lactic acidosis from point of care analysis: mind the gap D Brindley, P Brindley University of Alberta Hospital, Edmonton, Canada Critical Care 2010, 14(Suppl 1):P163 (doi: 10.1186/cc8395) Introduction A patient presented with severe acidosis, point-of-care (POC) lactate of 42 mmol/l. This led to suspicion of mesenteric ischemia and potential need for laparotomy. However, plasma lactates were <4 mmol/l, and ethylene glycol (EG) ingestion was subsequently diagnosed. We therefore wished to determine why discrepant lactates occur and whether this lactate gap (that is, the diference between lactate measured using two common methods) could be clinically useful. Methods We phlebotomized blood, added various concentrations of EG metabolites, and tested with the ive most common lactate analyzers. Results Glycolate caused massive artifactual lactate elevation with the Radiometer 700 POC analyzer even at low concentrations. Another major EG metabolite, glyoxylate, but not oxalate (or formate), caused similar elevation. The iSTAT and Bayer POC analyzers and Beckman and Vitros laboratory analyzers caused minimal lactate elevations. The lactate gap was determined by comparing the Radiometer with any of the other analyzers. Conclusions We demonstrated how inappropriate laparotomy or delayed-therapy might occur if clinicians are unaware of this phenomenon (now dubbed the lactate gap) or if hospitals only have access to a single analyzer. We also showed how the lactate gap can be exploited: to expedite treatment, diagnose late EG ingestion, and terminate dialysis. By comparing lactate results from the iSTAT or Bayer versus the Radiometer, EG ingestion can be diagnosed at POC, thereby further expediting diagnosis and treatment ahead of plasma EG. P164 Serum lactate on admission to intensive care and outcome: an observational cohort study A Mackay, H Simpson, L Strachan, T Quasim, M Booth Glasgow Royal Inirmary, Glasgow, UK Critical Care 2010, 14(Suppl 1):P164 (doi: 10.1186/cc8396) Introduction Lactate is an important substrate for intermediary metabolism and allows movement of carbon and reducing power between cells [1]. Its use as a measure of end organ perfusion and as a marker of tissue hypoxia in the critically ill is well established. It is suggested that a rise in serum lactate is a sensitive indicator of poor prognosis in this group [2]. We wished to identify whether or not this was the case in our patient population. Methods A retrospective case note review of 504 consecutive admissions to Glasgow Royal Inirmary ICU was undertaken over an 18-month period. Serum lactate on initial blood gas analysis following admission to intensive care was retrieved from the clinical information system. Demographic, APACHE II score and outcome data were retrieved from the Ward Watcher system in the ICU. Results Complete data were available for 454 patients. Demographics of the patient group were as follows: 65% were male with a mean age of 53.8 ± 1.5 years. Average length of stay was 6.1 ± 0.46 days with a median APACHE II score of 18 (IQR 12 to 24). Crude ICU and hospital mortalities were 28% and 34.7%, respectively. Mean lactate was 2.46 ± 0.24 mmol/l. We constructed an ROC curve for admission lactate vs ICU mortality with an area under the curve (AUC) = 0.66, P <0.001. ROC curve for APACHE II vs ICU mortality gives AUC = 0.80, P <0.001. Using univariate analysis and chi-square testing we found that, using diferent thresholds for lactate level, we were able to establish a relative risk of death for those exceeding this level as follows (RR, P value): >2 mmol/l (RR 1.29, P <0.001), >4 mmol/l (RR 1.63, P <0.001), >6 mmol/l (RR 2.08, P <0.001), >8 mmol/l (RR 3.43, P <0.001), >10 mmol/l (RR 3.43, P <0.001). Conclusions While using ROC analysis suggests serum lactate is of moderate predictive value for ICU mortality, applying serial increasing lactate cutof points and comparing those above and below these points suggests a strong relationship between increasing lactate level and increased risk of ICU mortality. References 1. 2. Leverve XM: Lactate in the intensive care unit. Crit Care 2006, 9:622-623. Bakker J, et al.: Blood lactate levels are superior to oxygen delivery variables in predicting outcome in human septic shock. Chest 1991, 99:956-962. P165 Physicochemical acid–base parameters and mortality in 1,070 ICU patients: a retrospective cohort study N Jones, S Gearay, D Bennett, M Terblanche St Thomas’ Hospital, London, UK Critical Care 2010, 14(Suppl 1):P165 (doi: 10.1186/cc8397) Introduction Acid–base disorders are common in ICU patients and are associated with increased mortality and morbidity. A physicochemical (PHYSCO) approach to acid–base abnormalities based on principles described by Stewart and Figge may explain various derangements better than traditional approaches. Recent data suggest an increased inorganic ion diference is associated with lower mortality in septic patients. We determined the efects of baseline and changes in PHYSCO parameters suggested by Stewart and Figge on 30-day mortality in a large cohort of unselected ICU patients. Methods We performed a retrospective cohort study using data obtained from the electronic clinical information system. All patients who underwent lactate and SvO2 measurement (from internal jugular or subclavian vein) during the irst 24 hours after ICU admission were included. Baseline, daily follow-up and 30-day mortality data were recorded. The worst recorded were used to calculate, for each day and for the change from day 1 to day 3, the following PHYSCO parameters: apparent strong ion diference (SIDa), inorganic SIDa (iSIDa; excludes lactate), efective SID (SIDe: includes pCO2, albumin, pH and phosphate) and strong ion gap (SIG; SIDa minus SIDe). Descriptive analysis used standard statistical techniques and univariate logistic regression (dependent variable 30-day mortality) assumed statistical signiicance at P <0.05. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Results A total of 1,544 patients were included. Complete data to calculate day 1 and day 3 parameters were available in 1,070 and 656 patients, respectively. Overall 30-day mortality was 21.3%. Mean (SD) age and APACHE II score were 63.0 (16.4) and 21.6 (6.9), respectively. For survivors versus nonsurvivors there were signiicant diferences in baseline SIDa (P = 0.03), iSIDa, SIDe, lactate and base excess (all P <0.001), but not in SIG (P = 0.1). An increased SIDa (P = 0.015) and SIDe (P <0.001), and decreased iSIDa and lactate (all P <0.001) but not SIG (P = 0.09) were predictive of mortality. For day 1 to day 3, only Δ-SIG was weakly predictive of mortality (OR 1.03 per 1 unit increase, P = 0.04, 95% CI = 1.00 to 1.05, n = 656) but there was no diference between survival groups (P = 0.051). Conclusions This study conirms recent data suggesting baseline diferences (but not changes over 3 days) in the relationships between strong and weak ions and pCO2 (relected in SIDa, lactate, and impacts on mortality). The diferent efects observed for SIG and BE imply a signiicant unmeasured acid load inluencing mortality. Bias and confounding may afect these indings and they should therefore be conirmed prospectively. P166 Accuracy of predicting arterial blood gases following mechanical ventilator adjustment H Al-Otaibi1, N Bedforth2, R Mahajan1, J Hardman1 1 The University of Nottingham, UK; 2Nottingham University Hospitals NHS Trust, Nottingham, UK Critical Care 2010, 14(Suppl 1):P166 (doi: 10.1186/cc8398) Introduction Clinicians adjust mechanical ventilator (MV) in critical care units to optimise arterial blood gases (ABG). The present study evaluates their accuracy in predicting ABG values following MV adjustment. Methods Thirty-one sets of data were collected from 16 patients requiring mechanical ventilation on the ICU. Each set consisted of two subsets – before and after MV adjustment. Each of subset consisted of the following variables: FIO2, respiratory rate (breaths/minute), tidal volume (ml/kg), body temperature (°C), haemoglobin concentration (g/dl), and ABG values (pH, PaCO2, PaO2, base excess). All data, with the exception of ABG values after MV adjustment, were presented to clinicians. Thirty-three clinicians (11 respiratory therapists (RTs), 11 nurses, and 11 medical staf ) were asked to predict the new ABG values as they would in clinical settings. All data are presented as mean ± SD unless stated otherwise. Results All datasets include changes in FIO2, while only 13 datasets include changes in minute ventilation. Increases in FIO2 were 0.19 ± 0.04 and decreases were –0.12 ± 0.04. Size of change of minute ventilation was 1.38 ± 0.95 l/minute. The absolute magnitudes of change for measured pH, PaCO2, and PaO2 were 0.024 ± 0.027, 0.40 ± 0.37 kPa and 5.91 ± 3.35 kPa, respectively. The magnitudes of change for predicted pH, PaCO2, and PaO2, respectively, were 0.025 ± 0.033, 0.34 ± 0.23 kPa, and 3.45 ± 2.03 kPa for medical staf ; 0.024 ± 0.021, 0.40 ± 0.41 kPa, and 3.91 ± 1.75 kPa for RTs; and 0.022 ± 0.015, 0.32 ± 0.22 kPa, and 3.21 ± 2.1 kPa for nurses. The 95% limits of agreement between predicted and measured size of changes for pH, PaCO2, and PaO2, respectively, were 0.043 to –0.041, 0.724 to –0.596 kPa, and 3.22 to –8.14 kPa for medical staf ; 0.036 to –0.036, 0.66 to –0.66 kPa, and 2.64 to –6.64 KPa for RTs; and 0.036 to –0.076, 0.74 to –0.9 kPa, and 3.91 to –9.31 kPa for nurses. Correlation between duration of clinicians’ clinical experience and errors in predicting size of change for pH, PaCO2, and PaO2 (–0.0225, –0.054, and 0.173, respectively) were weak and not statistically signiicant. Conclusions Clinicians show considerable variation in predicting ABG values. Medical staf and nurses underestimate the magnitude of PaCO2 changes whereas RTs show some accuracy. All clinicians have a large bias in predicting the size of PaO2 changes. P167 Use of capnography and the availability of airway equipment on UK intensive care units A Georgiou, S Gouldson, A Amphlett Frenchay Hospital, Bristol, UK Critical Care 2010, 14(Suppl 1):P167 (doi: 10.1186/cc8399) Introduction Provisional data from the 4th National Audit Project of the Royal College of Anaesthetists has identiied that at least 20% of major S58 airway events take place on the ICU and that these are more frequently fatal than events elsewhere (TM Cook, personal communication). Over 23% of these incidents relate to the instigation or maintenance of an artiicial airway [1]. Both the use of capnography and the immediate availability of airway rescue devices to avert or manage such incidents have been recommended. This study seeks to determine the adherence to these recommendations, the availability of such equipment on UK ICUs and to identify areas for safety improvement. Methods Every adult general, hepatobiliary and satellite ICU (grouped together as GICU), neurointensive care unit (NICU) and cardiac intensive care unit (CICU) in the UK was telephoned, thereby covering every area in the UK where ventilated adult patients are routinely cared for outside the operating theatre. Data were obtained from the nurse in charge over a 3-month period in 2009. Results In total, 315 of 328 contacted units responded (96% response). Capnography during intubation: 32% units use always, 43% sometimes and 25% never. Capnography for continuous monitoring of intubated patients: 25% units use always, 35% sometimes and 40% never. Of note, 45% of NICUs never use capnography for continuous monitoring (where doing so may prove most beneicial). Basic airway equipment (oropharyngeal airways, laryngoscopes and bougies), alternative means of patient ventilation and equipment checking procedures are seen on 97 to 100% of ICUs. A standard laryngeal mask (LMA) is available on 97% of ICUs. More advanced airway rescue devices are seen less commonly: 71% have a McCoy laryngoscope and 55% have a bougie through which ventilation is possible. Forty-three per cent have an intubating LMA and 21% have supraglottic airway with a gastric port immediately available. Forty-nine per cent of units have a bronchoscope on the ICU. Seventy per cent of units have equipment for emergency trans-tracheal access. CICUs are least likely to use capnography or have airway rescue equipment immediately available. Conclusions Basic standards of airway safety are not being met on UK ICUs and are far from the standards being routinely employed in the operating theatre. The potential airway diiculties presented by the ICU patient, together with the lack of routine use of capnography, exposes these patients to signiicant risks that may be easily addressed. Reference 1. Thomas et al.: Anaesthesia 2009, 64:358-365. P168 Combined oximetry and transcutaneous capnography is a reliable non-invasive monitoring in patients after cardiac surgery W Baulig, RR Roediger, O Theusinger, D Rusch, D Spahn University Hospital Zurich, Switzerland Critical Care 2010, 14(Suppl 1):P168 (doi: 10.1186/cc8400) Introduction The aim of this study was to validate the revised V-Sign™ 2 ear lobe sensor for combined assessment of pulse rate (PR), pulse oximetry (SpO2) and transcutaneous carbon dioxide tension (PtcCO2) in adults after cardiac surgery. Methods In 20 patients coevally readings of blood gases were compared with values of the V-Sign™ 2 ear lobe sensor. Measurements were performed during periods of hypercapnia, normocapnia and hypocapnia and then in intervals of 30 minutes up to 5 hours. Agreement was assessed by Bland–Altman analysis and single regression analysis. Results Two hundred and ninety-six data pairs were analysed. Detection failures for PtcCO2 were 1.3%, for SpO2 10% and for PR 5%. PtcCO2 and PaCO2 ranged between 3.58 and 7.70 kPa. Mean bias and limits of agreement (LOA) between PtcCO2 and PaCO2 was excellent (Table 1). The best agreement between PtcCO2 and PaCO2 was found during periods of Table 1 (abstract P168). Agreement between V-Sign™ 2 sensor and co-oximetry and ECG n (data pairs) r2 Mean bias Limits of agreement PtcCO2–PaCO2 (kPa) 296 0.92 +0.14 –0.45/+0.73 V-Sign™ SpO2–SaO2 (%) 270 0.59 –1.68 –6.81/+3.45 V-Sign™ PR-ECG (bpm) 285 0.98 +1.22 –3.31/+5.75 Parameter Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 hyperventilation and hypoventilation with a mean bias (LOA) of +0.18 kPa (–0.31/+0.67 kPa) and 0.07 kPa (–0.45/+0.59 kPa), respectively. At about 5 hours no relevant drift was observed between PtcCO2 and PaCO2. V-Sign™ 2 SpO2 moderately agreed and slightly underestimated SaO2 determined by direct oximetry, whereas pulse rate values detected by the V-Sign™ 2 ear lobe sensor agreed well with those of the ECG (Table 1). Conclusions Transcutaneous capnography using the V-Sign™ 2 ear lobe sensor reliably detects the ventilation state of patients after cardiac surgery. This non-invasive approach has the potential to reduce the number of arterial blood gas samples. P169 Computerized lung sound monitoring to assess efectiveness of physiotherapy and secretion removal: a feasibility study G Ntoumenopoulos1, Y Glickman2 1 Guy’s and St Thomas’ NHS Foundation Trust, London, UK; 2Deep Breeze Ltd, Or-Akiva, Israel Critical Care 2010, 14(Suppl 1):P169 (doi: 10.1186/cc8401) Introduction Intubation and mechanical ventilation impair secretion clearance and can lead to lung collapse, consolidation and ventilatorassociated pneumonia [1]. There is, however, no valid diagnosis of secretion retention in the intubated and ventilated patient. Vibration response imaging (VRI) is a commercially developed acoustic lung imaging system that displays breath sound distribution [2]. VRI should be able to identify relationships between speciic breath sound distributions and secretion retention. This preliminary study investigated the changes in VRI measurements before and after chest physiotherapy in adult intubated and mechanically ventilated patients. Methods Intubated and ventilated adult patients who were receiving chest physiotherapy were investigated. Lung sound amplitude at peak inspiration was measured immediately before and after chest physiotherapy using two arrays of sensors attached to the patient’s back in a supine position. Chest physiotherapy included combinations of closed airway suctioning, saline lavage, postural drainage, manual techniques and/or lung hyperinlation, dependent upon clinical indications. Means are compared with the Wilcoxon matched-pairs signed-ranks test. Results A total of 16 patients were included in the study (12 males, four females, age 65 ± 14). Patients were predominantly ventilated with continuous positive airway pressure and pressure support. Following physiotherapy, total lung sound amplitude at peak inspiration decreased twofold from 37 ± 58.106 to 18 ± 23.106 arbitrary units (AU), with signiicant reduction in the left lung (P = 0.03). Furthermore, the diference in sound amplitude between right and left lungs signiicantly decreased posttreatment compared with pretreatment (P = 0.03). Conclusions Computerized lung sound monitoring may be useful to assess secretion retention and the efectiveness of secretion removal in mechanically ventilated patients. Further investigation is, however, necessary in order to distinguish between secretion-related efects and changes due to other factors such as airlow rate and pattern. References 1. 2. Konrad et al.: Chest 1994, 105:237-241. Jean et al.: Anesth Analg 2008, 107:1243-1247. Figure 1 (abstract P171). S59 P170 Analysis of sound waves recorded with the VRI pulmonary acoustic monitoring system in critically ill mechanically ventilated patients S Lev1, YA Glickman2, M Shapiro1, PS Singer1 1 RMC, Petach Tiqva, Israel; 2Deep Breeze, Or Akiva, Israel Critical Care 2010, 14(Suppl 1):P170 (doi: 10.1186/cc8402) Introduction Posterior auscultation of mechanically ventilated patient is challenging. Environmental ICU noises make the detection of subtle auscultatory features diicult. Digitalized pulmonary acoustic monitoring has recently been introduced in the ICU. We explored the possibility to listen to sound waves recorded by the VRI system. Methods Lung sounds were recorded for 20 seconds using two arrays of 17 piezoelectric contact sensors attached to the patient’s back in a supine position. Sound iles were archived in a WAV format for oline analysis. Three physicians and one trained respiratory therapist, blinded to the patient’s clinical status, provided their indings while listening to sound waves recorded by 12 sensors distributed from apex to base, six from each lung. Breath sounds were categorized as normal versus abnormal and adventitious lung sounds were characterized as wheezes, rhonchi or crackles. Findings were compared with anterior stethoscope auscultation performed at the time of the recording by one of the physicians. Results Eighteen critically ill mechanically ventilated patients (age 65 ± 17) were enrolled in this study. Chest radiography (CXR) indings included consolidation in 13 patients. There was an agreement among at least three clinicians in the normal/abnormal classiication. Furthermore, in 10 out of these 15 patients (67%), this assessment based on sound wave analysis was in agreement with anterior stethoscope auscultation. Finally, the physician who performed both sound wave analysis and stethoscope auscultation reported crackles/rhonchi in ive out of 13 patients with consolidation (38%) during sound wave analysis but only in one patient during auscultation (8%). Conclusions The level of interobserver variability for sound wave characterization was comparable with levels usually reported during stethoscope auscultation. However, in patients with consolidation, a higher number of crackles/rhonchi was reported during posterior sound wave analysis than during anterior stethoscope auscultation. This discrepancy may be either due to the anterior/posterior orientation or to the higher sensitivity of the oline sound wave analysis. P171 Lung tissue properties obtained by optical alveolar elastometry D Schwenninger1, H Runck1, S Schumann1, K Möller2 1 University Medical Center of Freiburg, Germany; 2Furtwangen University, VS-Schwenningen, Germany Critical Care 2010, 14(Suppl 1):P171 (doi: 10.1186/cc8403) Introduction Knowledge of micromechanical properties of lung parenchyma is essential for understanding macroscopic lung mechanics. The irst results of in vivo and in situ measurements using an endomicroscopic device [1] are reported. The degree of local lung deformation in dependence of locally applied pressure is shown. Methods An endoscopic system including two concentric trocars was constructed to apply a deined local pressure within the ield of view (Pfov). Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 The endoscopic system was placed between the ribs of mechanically ventilated rats with the tip placed on the pleura. Pfov was applied to a circular area on to the lungs’ surface and led to a local deformation. By adjusting the low rate of the lushing luid from the outer trocar to the inner trocar, Pfov was varied. The resulting local deformation of lung parenchyma was optically measured by estimating the diameter of ceramic particles, ixed on the pleura for that purpose. Deformation was measured at diferent levels of airway pressure (Paw) with Pfov ramped from 0 to –40 mbar. Results The healthy lung (Figure 1A) parenchyma showed less deformation caused by luidic pressure compared with the lavaged lung (Figure 1B). In contrast to the lavaged lung, the deformation of the healthy lung was less when higher Paw was present. Conclusions Micromechanical properties of lung parenchyma can be analyzed in vivo at an alveolar level. The healthy lung parenchyma appears to be stifer (less deformation) at higher Paw. The stronger deformation and less dependence on airway pressure in the lavaged lung support the hypothesis that small lung compliance in lavaged lungs might not be reasoned by stif lung parenchyma, but rather by regional collapse. References 1. S60 Results Table 1 presents the main results of the study. Best PEEP was set at 10 cmH2O, at which level the decrease of FRC and improvement of Crs indicates the start of de-recruitment and end of overdistention. Table 1 (abstract P172) FRC ml PEEP 15 PEEP 10 PEEP 5 2,975 ± 644 2,412 ± 585* 2,059 ± 556** Crs ml/cm 33 ± 8 39 ± 9* 45 ± 10** PaO2/FIO2 310 ± 62 291 ± 78 185 ± 89† LVOT VTI cm 16.3 ± 2 20 ± 3* 22 ± 6** † *P <0.05. **P <0.01 vs PEEP 15. P <0.001 vs PEEP 15 and 10. Conclusions Increased levels of PEEP improve FRC. Combined monitoring of FRC and Crs may detect hyperinlation. Hyperinlation impairs LV systolic function. References 1. Lambermont B, et al.: Crit Care 2008, 12:R91. Schwenninger D, et al.: IEEE Trans Biomed Eng in press. P172 Combined monitoring of functional residual capacity and compliance may avoid hyperinlation and cardiac depression in ARDS F Turani, L Cococcia, R Barchetta, F Mounayeri, E Di Marzio, M Falco, A Marinelli European Aurelia Hospital, Rome, Italy Critical Care 2010, 14(Suppl 1):P172 (doi: 10.1186/cc8404) Introduction Combined monitoring of functional residual capacity (FRC) and compliance of the respiratory system (Crs) at the bedside may allow alveolar recruitment and detect hyperinlation [1]. The aims of this study were to evaluate the FRC by a modiied nitrogen multiple washout technique (NMBW) combined with the study of Crs, to set best PEEP on data of FRC and Crs, and to evaluate by echocardiography study the cardiac response to diferent levels of PEEP. Methods Thirty patients with ALI/ARDS were ventilated with an Engstrom carestation ventilator (GE Healthcare, Helsinki, Finland) in accordance with the ARDS net guidelines. FRC measurement was carried out with the COVX module integrated within the ventilator (GE Healthcare) by the NMBW technique. Every patient had a basal FRC measurement and then three measurements at PEEP 15/10/5 cm H2O during a de-recruiting maneuver. At every step we studied the changes of FRC, Crs, PaO2/FIO2 ratio and performed a transthoracic echocardiography (Agilent 5500; Hewlett and Packard) to evaluate the integral of velocity time of left ventricular outlow tract (LVOT VTI). All data are reported as mean ± SD. ANOVA was used to compare changes during the time. Figure 1 (abstract P173). P173 Electrical impedance tomography at two thoracic levels provides detailed information about ventilation distribution in the cranial to caudal direction I Bikker, C Preis, J Bakker, D Gommers Erasmus Medical Center, Rotterdam, the Netherlands Critical Care 2010, 14(Suppl 1):P173 (doi: 10.1186/cc8405) Introduction Electrical impedance tomography (EIT) is a promising new tool for bedside monitoring of regional lung ventilation. Several studies have focused on the ventilation distribution and relationship with regional lung volume on a lower, caudal lung level. However, no information is available at a higher, cranial lung level. Methods EIT (EIT Evaluation Kit 2; Dräger, Lübeck, Germany) was measured at cranial and caudal lung levels in 10 patients after cardiothoracic surgery. Patients were fully sedated and mechanically ventilated and a PEEP trial was performed at four PEEP levels (15, 10, 5 and 0 cmH2O). Results The center of gravity index decreased after lowering the PEEP level at both the caudal and cranial lung levels (Figure 1 right). Whereas the tidal volume impedance variation divided by tidal volume increased at the cranial lung level and decreased at the caudal lung level during the step-wise reductions in PEEP (Figure 1 left). Conclusions During decremental PEEP steps, the ventilation distribution not only shifts from a dorsal to ventral direction, but also from the caudal to cranial direction. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P174 Changes in regional ventilation determined by volume and pressurecontrolled ventilation as assessed by electrical impedance tomography in an experimental model of acid-induced acute lung injury CA Holms, DA Otsuki, J Noel-Morgan, M Kahvegian, DT Fantoni, JO Auler Jr Faculdade de Medicina da Universidade de São Paulo, Brazil Critical Care 2010, 14(Suppl 1):P174 (doi: 10.1186/cc8406) Introduction Electrical impedance tomography (EIT) is a promising bedside tool for monitoring regional lung ventilation during mechanical ventilation [1]. The purpose of this study was to assess regional lung ventilation by EIT in a pig model of acid-induced acute lung injury (ALI) during pressurecontrolled (PCV) and volume-controlled ventilation (VCV). Methods Ten anesthetized and tracheotomized female pigs (25 to 30 kg) were randomized into two groups: mechanical ventilation by PCV (pressure adjusted to achieve and maintain 8 ml/kg tidal volume, n = 5) or VCV (8 ml/kg, n = 5) in FiO2 50%. ALI was induced in both groups by intratracheal instillation of 4 ml/kg hydrochloric acid (HCl) 0.1 N. Impedance changes (Draeger, Germany) were recorded by a 16-electrode belt placed at the level of the sixth intercostal space, and four horizontal, equally-sized regions of interest (ROIs) were deined for oline data analysis. Measurements were performed before (T-BL) and after lung injury (T-ALI). Lung tidal volume (Vt), pulmonary static compliance (Cstat), pulmonary mean artery pressure (mPAP), peak pressure (Pp), respiratory rate (RR) and PaO2/FiO2 ratio were also recorded. Statistical analysis was based on two-way ANOVA followed by the Tukey test for analysis of data within and between groups, and a t test was used analysis of impedance changes induced by ALI. Results After ALI, both PCV and VCV groups showed signiicant decreases in the PaO2/FiO2 ratio (479.6 ± 46.5 to 244.5 ± 64.7 and 428.8 ± 22.9 to 212.4 ± 26.7) and Cstat (29.2 ± 5.1 to 13.2 ± 2.3 and 26.6 ± 3.4 to 12.3 ± 3.2) and signiicant increases in Pp (14.2 ± 1.9 to 25.6 ± 2.6 and 13.8 ± 0.8 to 24.6 ± 4.16) and mPAP (19.6 ± 0.5 to 35.2 ± 5.8 and 19.4 ± 1.5 to 26.8 ± 4.5). Between groups, only mPAP was statistically diferent at T-ALI. Global impedance decreased slightly after ALI in both groups, with no statistical signiicance. At T-ALI, there were statistically signiicant diferences in tidal distributions of ROIs 2 (38.9 ± 2.6% to 42.4 ± 3.9%) and 3 (39.7 ± 3.1 to 35.1 ± 4.3%) of animals in the VCV group, when compared with T-BL. No signiicant diference was found in the PCV group. Conclusions EIT assessment of ventilation revealed a ventral shift in the tidal distribution in the VCV group after ALI, while PCV preserved tidal distribution observed at baseline. Acknowledgements Grants from FAPESP (08/55376-7 and 08/56792-4) and LIM08/FMUSP. Reference 1. Frerichs I, et al.: Physiol Meas 2007, 28:S261-S267. P175 Changes in lung tidal distribution assessed by electrical impedance tomography in a model of hemorrhagic shock with endotoxemia and resuscitation J Noel-Morgan, DT Fantoni, DA Otsuki, CA Holms, JO Auler Jr Faculdade de Medicina da Universidade de São Paulo, Brazil Critical Care 2010, 14(Suppl 1):P175 (doi: 10.1186/cc8407) Introduction Electrical impedance tomography (EIT) is a non-invasive bedside imaging tool with the potential to assess regional lung ventilation reliably [1]. The purpose of this study was to monitor changes in lung impedance in a pig model of severe shock followed by luid resuscitation. Methods Twelve anesthetized, mechanically ventilated (8 ml/kg, PEEP 5 cmH2O), supine pigs were submitted to acute hemorrhagic shock with infusion of endotoxin. Animals were allocated to positive control (PC, n = 6) or treatment group with lactated Ringer’s to achieve and maintain pulse pressure variation 13% and mean arterial pressure 65 mmHg (PPV, n = 6). Ventilatory and hemodynamic parameters were recorded at baseline, 1 hour after hemorrhagic shock (Tshock), and hourly for 3 hours (T1 to T3). A 16-electrode belt was placed at the level of the sixth intercostal space for EIT measurements (Dräger, Germany). Oline analysis was based on four horizontal regions of interest (ROIs) over the ventrodorsal lung area. Statistical analysis was based on two-way ANOVA followed by the Tukey test (P <0.05). S61 Results At Tshock there was hemodynamic compromise, statistical decrease in lung compliance (Cstat) and signiicant increases in pulmonary vascular resistance index, mean pulmonary artery pressure and peak pressure (Ppeak), with no statistical diference between groups. Endpoints and hemodynamic stability were achieved in the PPV group in 117 ± 28 minutes. Cstat continued to deteriorate and Ppeak continued to rise in both groups from T1 to T3. When compared with PC, the PPV group had signiicant impedance increases in ROIs 1 and 2 at T2 and T3 and, at T3 the increase in ROI 1 was also statistically greater than Tshock within the group. Statistical decrease in the percentage tidal distribution in ROI 3 and increase in ROI 2 of the PPV group, in relation to the PC group, were also noted. Conclusions Despite re-establishment of hemodynamic adequacy in PPV group and although ventilatory parameters were similar in both groups over time, resuscitation as performed in the study induced signiicant changes in tidal impedance toward nondependent lung regions, implying greater lung impairment in treated animals. Acknowledgements Grants from FAPESP 08/50063-0, 08/50062-4 and LIM08/FMUSP. Reference 1. Victorino et al.: Am J Respir Crit Care Med 2004, 169:791-800. P176 Estimating the intratidal compliance proile with the new gliding-SLICE method S Schumann1, B Burcza1, C Haberthuer2, M Lichtwarck-Aschof3, J Guttmann1 1 University Medical Center, Freiburg, Germany; 2Kantonsspital, Luzern, Switzerland; 3University of Uppsala, Sweden Critical Care 2010, 14(Suppl 1):P176 (doi: 10.1186/cc8408) Introduction At the bedside, but even in most research work, the analysis of respiratory system mechanics is limited to quasi-static conditions excluding any insight into what happens during the breath. The new gliding-SLICE method helps looking into the breath. It is a further development of the SLICE method for calculating compliance and resistance of subsequent intratidal volume ranges (slices) of the pressure– volume (PV) loop by multiple linear regression analysis in a continuous way. This allows for detecting intratidal compliance and resistance nonlinearity during ongoing ventilation. Our objective was to determine whether the nonlinear intratidal compliance proile hints at what level to set PEEP and tidal volume (VT) to make lung ventilation protective. Methods In 12 piglets, atelectasis was induced by application of negative pressure. The PV relationship and the ECG signal were recorded during mechanical ventilation at diferent levels of end-expiratory pressure (PEEP: 0, 5, 10 and 15 cmH2O) and a VT of 12 ml/kg BW. Using the gliding-SLICE method [1], intratidal compliance proiles were calculated and compared with the conventional quasi-static compliance. Results In contrast to quasi-static compliance, the gliding-SLICE method revealed pronounced intratidal nonlinearity of the compliance proile under ongoing ventilation (Figure 1). At low levels of PEEP, intratidal compliance increased in the low volume range, remained at a high level while further volume was delivered, and inally decreased with volume >6 ml/kg BW. With higher levels of PEEP, intratidal compliance decreased from the onset of inspiration. Conclusions The gliding-SLICE method gives detailed insights into the intratidal course of compliance during uninterrupted ventilation. From Figure 1 (abstract P176). Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 the proile of the intratidal compliance, the occurrence of intratidal recruitment and/or overdistension can be identiied. Reference 1. Schumann S, Burcza B, Haberthür C, Lichtwarck-Aschof M, Guttmann J: Physiol Meas 2009, 30:1341-1356. P177 Atelectasis and overdistension are detected by heartbeat-induced disturbances in the pressure–volume loop S Schumann1, L Vimlati2, K Moeller3, A Wahl1, R Kawati2, J Guttmann1, M Lichtwarck-Aschof2 1 University Medical Center, Freiburg, Germany; 2University of Uppsala, Sweden; 3HS Furtwangen University, Furtwangen, Germany Critical Care 2010, 14(Suppl 1):P177 (doi: 10.1186/cc8409) Introduction Heartbeats transfer mechanical energy to the lungs causing low and pressure disturbances that appear as cardiogenic oscillations (COS) at the airway opening. Here we adopt a new approach for analyzing respiratory system mechanics. We consider the beating heart as a natural intrathoracic mechanical oscillator transferring mechanical energy to the lungs that travels across the lung parenchyma. COS therefore convey information on the mechanical conditions of the lung parenchyma that they cross. Methods In 25 piglets with either healthy or atelectatic lungs, the pressure– volume relationship and the ECG signal were recorded during mechanical ventilation at diferent levels of end-expiratory pressure (PEEP: 0, 5, 10 and 15 cmH2O). The heartbeat-related disturbance of the PV loop was quantiied as the maximal compliance following an R-wave in the ECG signal, as determined by the gliding-SLICE method. Atelectasis was assessed by CT. Results The intratidal pattern of heartbeat-induced CCOS changed with PEEP and atelectasis in a characteristic way. With PEEP and tidal volume levels assumed to be lung protective CCOS was high with little intratidal changes, compared with atelectasis and overdistension that were signaled by low CCOS that either increased (atelectasis) or decreased (overdistension) intratidally. The systolic pressure variations did not parallel the CCOS pattern, hinting at a negligible impact of hemodynamics on the inspiratory CCOS pattern. Conclusions Heartbeats induce luctuations in the PV loop and, as a consequence, peaks in compliance, which show characteristic patterns depending on the presence of atelectasis or overdistension. The gliding-SLICE method has the potential to detect those intratidal nonlinearities without requiring additional technical equipment making use of the ECG signal and the pressure and low signals already required for controlling the ventilator. P178 Transpulmonary pressure and ventilation distribution measured with EIT during a PEEP trial in porcine acute lung injury I Bikker, B Vd Berg, P Specht, J Bakker, D Gommers Erasmus Medical Center, Rotterdam, the Netherlands Critical Care 2010, 14(Suppl 1):P178 (doi: 10.1186/cc8410) Introduction Setting the optimal level of positive end-expiratory pressure (PEEP) in the ICU is still a matter of debate. Talmor and colleagues used Figure 1 (abstract P178). S62 the transpulmonary pressure calculated from the oesophageal balloon to set PEEP in a recent randomized controlled study. This strategy aims at preventing alveolar collapse by counterbalancing the gravitational force of the lung by an equal or higher PEEP. We evaluated the relation between ventilation distribution measured by EIT and transpulmonary pressure during a PEEP trial in porcine ALI. Methods Eight pigs (30 kg) were studied during a PEEP trial before and after the induction of acute lung injury (ALI) with oleic acid. Global lung parameters, regional compliance, and oesophageal pressure were recorded at the end of each PEEP step. Regional compliance was calculated by dividing the tidal impedance variation (EIT Evaluation Kit 2; Dräger, Lübeck, Germany) by the applied driving pressure. Results Transpulmonary pressures were negative at 0 cmH2O PEEP and became positive during the stepwise increase of PEEP at 5 cmH2O before, and 10 cmH2O PEEP after the induction of ALI (Figure 1). Optimum regional compliance was diferent between the ventral (nondependent) and dorsal (dependent) regions of interest (ROI). In the healthy lung, optimum PEEP was 10 in the dorsal ROI and 5 in the ventral ROI, whereas after ALI this was 15 in the dorsal ROI and 5 in the ventral ROI. Conclusions If EIT is measured at a caudal lung level, optimal EIT PEEP in the dependent lung exceeds the PEEP required for positive transpulmonary pressures as used in the Talmor study, whereas in the nondependent lung optimal EIT PEEP is equal before ALI and lower after ALI. We speculate that this is probably inluenced by the location of the EIT slice in the cranial to caudal direction. P179 A prospective pilot study of the efect of neutrophil elastase on the pulmonary vascular permeability in patients with pneumonia T Tagami1, R Tosa1, H Hirama1, K Yonezawa1, M Omura1, G Akiyama1, T Masuno2, Y Yamamoto2, S Kushimoto2, H Yokota2 1 Aizu Chuo Hospital, Aizuwakamatsu, Fukushima, Japan; 2Nippon Medical School, Tokyo, Japan Critical Care 2010, 14(Suppl 1):P179 (doi: 10.1186/cc8411) Introduction Some cases of pneumonia may lead to hypoxemia with acute respiratory failure, acute lung injury (ALI) or acute respiratory distress syndrome (ARDS), which may require intensive management. Neutrophil elastase is thought to be one of the causes of ALI/ARDS, because it raises the pulmonary capillary permeability, lyses of pulmonary connective tissue proteins, and produces leukocyte chemotactic factors. However, a causal relationship between the plasma neutrophil elastase level and changes in the pulmonary capillary permeability has not been established in patients with pneumonia, one of the most serious diseases underlying ALI/ARDS. Therefore, the objective of this study was to determine whether an increase in plasma neutrophil elastase is related to elevation of the pulmonary capillary permeability in patients with pneumonia. Methods Patients with pneumonia who were hospitalized from November 2008 to April 2009 and had PaO2 ≤60 in room air with no need for mechanical ventilation were prospectively enrolled in the study. Plasma neutrophil elastase levels were collected via blood samples at baseline; 1, 3, and 7 days after the start of the study. Of those enrolled, patients with Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S63 PaO2/FiO2 ≤150 also had their extravascular lung water index (EVLWi) and pulmonary vascular permeability index (PVPI) monitored using the PiCCO system (Pulsion, Munich, Germany) when required by their attending physician. Statistical analysis was performed using the Spearman correlation coeicient (Rs) with P ≤0.05 assumed to be signiicant. Results Fourteen patients were enrolled in the study. In six of these patients, the EVLWi and PVPI were measured simultaneously. At baseline, the elastase level and the PVPI showed a strong and signiicant correlation (Rs = 1.000, n = 6, P <0.05). All of the plot data of the six patients showed strong correlations of the elastase level with the EVLWi (Rs = 0.750, n = 25, P <0.01) and the PVPI (Rs = 0.811, n = 25, P <0.01). Conclusions The plasma neutrophil elastase level and the PVPI measured by PiCCO were strongly correlated in patients with pneumonia. This suggests that a rise in the blood level of elastase may elevate the PVPI, resulting in an increased EVLWi. (UMIN Clinical Trials Registry: ID UMIN000002803.) P180 Evaluating the ibroproliferative response to ventilator-induced lung injury G Curley1, M Contreras1, B Higgins1, D O’Toole1, C O’Kane2, JG Lafey1 1 National University of Ireland, Galway, Ireland; 2Queens University Belfast, UK Critical Care 2010, 14(Suppl 1):P180 (doi: 10.1186/cc8412) Introduction Acute lung injury (ALI), and its more severe subset acute respiratory distress syndrome (ARDS), are a major cause of mortality in the ICU [1]. Mechanical ventilation, a supportive therapy necessary to sustain life in many cases, may contribute to and worsen ALI, termed ventilatorinduced lung injury (VILI). Fibroproliferation is an early response to lung injury [2]. Indeed, dysregulated repair resulting in pulmonary ibrosis may be at the heart of ventilator dependence in ARDS. Characterising the role of excessive lung stretch in contributing to aberrant repair mechanisms would assist in developing strategies to hasten recovery from ARDS. Methods Male Sprague–Dawley rats were anaesthetized, orotracheally intubated and subjected to injurious ventilation until a deined worsening of compliance was noted. The rats were then recovered and extubated. The level of ongoing injury/repair was characterised at time periods of 6, 24 and 48 hours and at 4, 7 and 14 days. Systemic oxygenation, lung compliance, wet/dry ratio, BAL total protein, cytokines and cell count and histological analysis was carried out at each time point. Results The results demonstrated a time-course-dependent improvement in compliance and oxygenation, together with clearance of neutrophilic iniltration at 96 hours. TNFα, and IL-1β, IL-6 and IL-10 were signiicantly elevated in BAL luid early post injury. Although total lung collagen remained similar at all time points, evidence of an early ibroproliferative response was present in the form of transforming growth factor-β activation and pro-collagen I and III peptide mRNA levels. Matrix metalloproteinase 3 and 9 zymography demonstrated increased levels of these matrikines. Histologic assessment of injury revealed increased alveolar tissue fraction up to and including 96 hours post injury. Myoibroblasts were present in α-smooth muscle actin stained sections in signiicantly increased numbers post injury. Conclusions This rat model of repair of VILI demonstrates some of the mechanisms by which excessive lung stretch can contribute to ibroproliferation in ARDS and will serve to improve our knowledge of aberrant lung tissue remodelling as well as provide a useful paradigm for testing strategies to hasten recovery in ALI. References 1. 2. Rubenfeld GD, Herridge MS: Chest 2007, 131:554-562. Marshall RP, et al.: Am J Respir Crit Care Med 2000; 162:1783-1788. P181 Efects of severe hemorrhage on pulmonary mechanics in ventilated pigs with ARDS N Siegenthaler1, R Giraud1, D Morel1, C Wiklund2, K Bendjelid1 1 Hôpital Cantonal Universitaire, Genève, Switzerland; 2Karolinska University Hospital, Stockholm, Sweden Critical Care 2010, 14(Suppl 1):P181 (doi: 10.1186/cc8413) Introduction The efects of hemorrhagic shock on respiratory system mechanics have rarely been investigated and published data are Figure 1 (abstract P181). Respiratory system compliance. Tidal volume, 10 ml/kg. controversial. Pulmonary compliance depends in part on intrapulmonary blood and interstitial luid volume. When compliance is severely reduced, small modiication of these components may have important efects. The present analysis explored the efect of hemorrhagic shock on respiratory system mechanics and oxygenation parameters in a model of pigs with ARDS. Methods We evaluated the dynamic respiratory system compliance (Crs = VT / (inspiratory airways pressure – PEEP)) of 14 domestic pigs. Animals were mechanically ventilated: tidal volume (VT) set at 10 ml/kg; respiratory rate at 15 bpm; PEEP at 0 cmH2O. Animals were separated into a control group (n = 9) and an ARDS group (n = 5). ARDS was induced by lung lavage with NaCl 0.9%. During hemorrhage 40% of the total blood volume was removed. The blood was then infused during the re-transfusion phase. Results In the control group, Crs (ml/cmH2O) did not change during hemorrhage or re-transfusion (Figure 1). In the ARDS group, Crs decreased with lung lavage (31.2 ± 5.7 (baseline) to 16.4 ± 3.0; *P <0.01). After hemorrhage Crs increased (21.5 ± 2.9; **P <0.001 compared with lavage) and then decreased again after re-transfusion (18.7 ± 2.7; ***P <0.05). In the same group PaO2/FiO2 (mmHg) decreased after ARDS (469 ± 50 (baseline) to 105 ± 38; P <0.001), increased during hemorrhage (218 ± 105; P <0.05) and did not change after re-transfusion (207 ± 125; P = 0.82). The shunt fraction (%) decreased during hemorrhage in the ARDS group (26.2 ± 14.9 (lavage) to 6.4 ± 6.6; P <0.05) but did not change signiicantly after re-transfusion (13.9 ± 17.0; P = 0.3). Conclusions Acute reduction of blood volume is associated with an increase of respiratory system compliance and oxygenation parameters. Reduction of intrapulmonary blood and interstitial luid volume or thoracic cage compliance could be responsible for this efect. P182 Higher versus lower positive end-expiratory pressure in acute lung injury and acute respiratory distress syndrome: systematic review and individual patient data meta-analysis MB Briel1, MO Meade2, A Mercat3, RG Brower4, D Talmor5, AS Slutsky6, DJ Cook2, L Brochard7, JC Richard8, F Lamontagne9, T Stewart6, GH Guyatt2 1 University Hospital Basel, Switzerland; 2McMaster University, Hamilton, Canada; 3University Hospital Angers, France; 4Johns Hopkins University, Baltimore, MD, USA; 5Harvard Medical School, Boston, MA, USA; 6University of Toronto, Canada; 7Paris 12 University, Creteil, France; 8University Hospital Charles Nicolle, Rouen, France; 9University of Sherbrooke, Canada Critical Care 2010, 14(Suppl 1):P182 (doi: 10.1186/cc8414) Introduction Trials comparing higher versus lower levels of positive end-expiratory pressure (PEEP) in adults with acute lung injury or acute respiratory distress syndrome (ARDS) were underpowered to detect small but important efects on mortality, overall or in any subgroups. Methods We searched MEDLINE, Embase, and the Cochrane Central Register for trials randomly assigning adults with acute lung injury or ARDS to higher versus lower levels of PEEP (minimal diference of 3 cmH2O over irst 3 days), while using low tidal volume ventilation, and comparing mortality. Data from 2,299 individual patients in three trials Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 were analyzed using uniform outcome deinitions. We tested prespeciied efect modiiers using multivariable hierarchical regression, adjusting for important prognostic factors and clustering efects. Results Overall, there were 374 hospital deaths (32.9%) in the higher PEEP group and 409 (35.2%) in the lower PEEP group (adjusted relative risk, 0.94; 95% conidence interval (CI), 0.86 to 1.04; P = 0.25). Treatment efects varied with the presence or absence of ARDS, deined by a ratio of partial pressure of oxygen to fractional inspired oxygen concentration equal to or less than 200 mmHg (interaction P = 0.02). The relative risks of hospital mortality for patients with and without ARDS were 0.90 (95% CI, 0.81 to 1.00, P = 0.049) and 1.37 (95% CI, 0.98 to 1.92, P = 0.065), respectively. Patients with ARDS were more likely to achieve unassisted breathing earlier (hazard ratio, 1.16 (95% CI, 1.03 to 1.30, P = 0.01); whereas the hazard ratio for time to unassisted breathing was 0.79 (95% CI, 0.62 to 0.99, P = 0.04) in patients without ARDS at baseline. Rates of pneumothorax and the use of neuromuscular blockers, vasopressors and corticosteroids were similar. Conclusions Higher levels of PEEP are likely to improve survival for patients with ARDS, but not for patients with less severe acute lung injury. P183 Efect of diferent recruitment maneuvers on bacterial translocation P Ergin Ozcan, I Edipoğlu, IO Akıncı, E Senturk, S Baylan, AA Cagatay, F Esen, L Telci, N Cakar Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey Critical Care 2010, 14(Suppl 1):P183 (doi: 10.1186/cc8415) Introduction Experimental and clinical studies have shown beneicial efects of recruitment maneuvers (RMs) (sustained inlation (SI) or SIGH) on ventilatory and gas exchange parameters. In this study we investigated the efect of diferent RMs on bacterial translocation from lung to blood. Methods Thirty-two rats were anesthetized, after tracheotomy was performed ventilation was started with 10 cmH2O Paw, 0 cmH2O PEEP, 60 breaths/minute, I/E: 1/2 on pressure-controlled ventilation (PCV) mode. After cannulation of the carotid artery was performed, a baseline blood gas sample was taken. Subsequently 0.5 ml of 105 cfu/ml Pseudomonas aeruginosa was inoculated through the tracheotomy tube and PEEP was increased to 3 cmH2O and ventilated for 30 minutes before randomization. Then rats were randomized into four groups: G1; SI was performed as 40 cmH2O PEEP and 0 Paw for 20 seconds, four times in an hour (15-minute intervals), G2; SI was performed as 20 cmH2O PEEP and 0 Paw for 40 seconds, four times in an hour (15-minute intervals), G3; SIGH was performed four times in 1 hour (15-minute intervals) as 40 cmH2O Paw, 3 mH2O PEEP for 60 seconds, G4; control group that was ventilated with Paw 10 cmH2O, PEEP 3cmH2O during the study period. Multiplication of pressure and pressure performing time for each study group were equal. Blood cultures were taken at baseline, 15 minutes after randomization, which is after each RM for the irst hour, and last blood culture was taken after 60 minutes from the fourth RM. Then rats were sacriiced with intra-arterial sodium Figure 1( abstract P184). S64 thiopental, and the lungs were extirpated; the left lung was taken for measurement of the wet weight/dry weight ratio (WW/DW). Results There were no diferences in baseline pH, PaO2, PaCO2, MAP, HR among groups. But PaO2 were decreased in groups G1, G2, and G3, but only in G3 was statistically signiicant to compared baseline values. The WW/DW ratio was found higher in G3 when compared with G1, and G2, but this diference was not signiicant. The amount of positive blood culture was higher in G3 at early study periods. Conclusions SIGH as a recruitment maneuver causes a high probability of bacterial translocation from the lung to the bloodstream. P184 Nonlinear recruitment model with viscoelastic component it respiratory mechanics in ARDS C Schranz1, J Guttmann2, K Möller1 1 Department of Biomedical Engineering, Furtwangen University, Villingen-Schwenningen, Germany; 2Section of Experimental Anesthesiology, University Hospital Freiburg, Germany Critical Care 2010, 14(Suppl 1):P184 (doi: 10.1186/cc8416) Introduction Alveolar recruitment/de-recruitment (R/D) seems to play an important role in the development of VILI [1]. Many clinicians base their determination of PEEP settings during mechanical ventilation of ARDS/ ALI patients on an estimate of alveolar recruitability [2]. This project aims to establish an online tool that provides estimates of R/D in patients at the bedside. Methods In volume-controlled ventilated piglets as ARDS models, the airway pressure Paw (SI-Special Instruments, Nördlingen, Germany) and the low rate Q (F + G GmbH, Hechingen Germany) were continuously recorded at 200 Hz. The pressure curve shows high nonlinearity being a suspect of recruitment efects during inspiration and a relaxation process during the end inspiratory pause. Based on the obtained data, the parameters of the linear viscoelastic model [3] are calculated by a LSE itting process. As the parameter C1 represents a static constant compliance of the lung, this model is not capable of reproducing the nonlinear efects during inspiration. To improve on this, the constant compliance C1 is replaced by a nonlinear pressure-dependent compliance describing recruitment and dilatation as proposed by Hickling [1]. Results Since the nonlinear model has far more variable parameters to be optimized in the itting process than the linear model, an approach via itting the linear model irst is helpful. Therefore, the estimated parameters of the linear model it can be used as starting values for itting the nonlinear model where the focus can be put on the recruitment phenomena. With the new nonlinear model, using the estimated values of R1, R2, C2 from the linear model (Figure 1 left), it is now possible to reproduce the nonlinear characteristics (Figure 1 right). Conclusions Using this new model it is possible to it nonlinear behavior due to alveolar recruitment separately from viscoelastic efects with minimized error. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S65 References 1. 2. 3. Hickling KG: Am J Respir Crit Care Med 2001, 163:69-78. Gattinoni L, et al.: N Engl J Med 2006, 354:1775-1786. Bates JH, et al.: J Appl Physiol 2002, 93:705-713. P185 Lung recruitment and PEEP response in ARDS-related H1N1 virus patients D Chiumello1, C Mietto2, V Berto2, A Marino2, E Gallazzi2, D Tubiolo1 1 Fondazione IRCCS, ‘Ospedale Maggiore Policlinico Mangiagalli Regina Elena’ di Milano, Milan, Italy; 2Università degli Studi di Milano, Milan, Italy Critical Care 2010, 14(Suppl 1):P185 (doi: 10.1186/cc8417) Introduction Starting in April 2009 the swine-origin inluenza (H1N1) virus is considered a worldwide pandemic and is associated with a large number of patients admitted to intensive care. In a proportion of these patients, acute respiratory distress syndrome (ARDS) can develop. We described the case of two patients that presented ARDS related to H1N1 virus conirmed by a nasal swab tested with real-time reverse transcription-polymerase chain reaction. Using a lung CT scan we measured the potential of lung recruitment and the response to positive end-expiratory pressure (PEEP) in terms of gas exchange and respiratory mechanics. Methods Patients underwent a lung CT scan at an airway pressure of 5 and 45 cmH2O; lung proiles were outlined and quantitative analysis was performed with custom-made software. The potential of lung recruitment was computed as the amount of nonaerated lung tissue at 5 cmH2O in which aeration can be restored at an airway pressure of 45 cmH2O. The PEEP test was performed at two PEEP levels (5 and 15 cmH2O), maintaining constant the minute ventilation and the inspiratory oxygen fraction; gas exchange and respiratory mechanics were recorded 20 minutes after each PEEP change. Results Two sedated and paralyzed subjects with acute lung injury (ALI)/ ARDS (age 46 ± 5 years, BMI 38.6 ± 5.5 kg/m2, PaO2/FiO2 187 ± 30 mmHg, PEEP 17 ± 1 cmH2O; both patients were obese and one of them sufered from diabetes) were enrolled. One patient required extracorporeal membrane oxygenation support for 5 days. Lung CT scans were performed 5 ± 3 days after ICU admission. The total lung weight at 5 cmH2O was 1,598 ± 142 g. The percentage of potentially recruitable lung was 24 ± 8% of the total lung weight, corresponding to an absolute weight of 371 ± 109 g recruitable lung tissue. A 15 cmH2O compared with 5 cmH2O of PEEP improved the compliance of the respiratory system from 42.2 ± 7.0 to 46.6 ± 2.1 ml/cmH2O and the gas exchange from PaO2 62.7 ± 0.1 to 123.2 ± 61.8 mmHg and PaCO2 47.1 ± 0.9 to 45.9 ± 3.2 mmHg, respectively. Conclusions The ARDS-related H1N1 virus presented, in the early phase, a high potentially recruitable lung in which elevated PEEP levels can be beneicial. P186 Maximal recruitment strategy minimizes tidal recruitment in severe ARDS: a CT scan study G Matos1, J Borges2, V Okamoto2, C Carvalho2, M Amato2, C Barbas1 1 Hospital Albert Einstein, São Paulo, Brazil; 2Universidade de São Paulo, Brazil Critical Care 2010, 14(Suppl 1):P186 (doi: 10.1186/cc8418) Introduction The maximal recruitment strategy (MRS) is considered an eicient maneuver to reverse nonaerated lung in ARDS patients. There is no information regarding tidal recruitment during MRS. Methods Early and severe ARDS patients were submitted to MRS guided by thoracic CT: A – recruitment phase (PEEP 10 to 45 cmH2O and constant driving pressure 15 cmH2O); B – PEEP titration phase (PEEP 25 to 10 cmH2O). Images were obtained at end expiration and inspiration. Global and regional quantitative CT analyses from each step of PEEP were compared [1]. Results Analyses of 12 patients showed that MRS reduced signiicantly the global amount of nonaerated tissue (54 ± 8% to 7 ± 6%, P <0.01), tidal recruitment (4 ± 4% to 1 ± 1%, P = 0.029) (Figure 1). Most dependent regional tidal recruitment signiicantly increased from PEEP 10 to 20 cmH2O (2 ± 3% to 11 ± 7%, P <0.01), but signiicantly decreased after MRS (11 ± 7% to 2 ± 2%, P <0.01). High PEEP (25 cmH2O) was necessary to sustain recruitment. Figure 1 (abstract P186). Percentage of regional (I to IV) tidal recruitment during all steps of the MRS protocol. Conclusions MRS decreased nonaerated areas and tidal recruitment. Increasing PEEP without full recruitment may cause lung injury exacerbation in the severe ARDS population. References 1. Borges JB, et al.: Reversibility of lung collapse and hypoxemia in early acute respiratory distress syndrome. Am J Respir Crit Care Med 2006, 174:268-278. P187 Mechanical ventilation with diferent alveolar pressures improves alveolar recruitment: a model study Z Zhao1, J Guttmann2, K Möller1 1 Furtwangen University, Villingen-Schwenningen, Germany; 2University Medical Center Freiburg, Germany Critical Care 2010, 14(Suppl 1):P187 (doi: 10.1186/cc8419) Introduction In patients with acute respiratory distress syndrome (ARDS) tidal ventilation is always inhomogeneous, with atelectasis in dependent lung and overdistention in nondependent lung. The aim of our study was to develop a low pattern that simultaneously produces locally diferent alveolar pressures, in order to recruit collapsed alveoli and at the same time to prevent hyperinlation of already open alveoli. Methods We modiied Horsield’s model of the canine lung [1] to predict alveolar pressure diferences between the collapsed and opened alveoli. The morphometric model has an asymmetrical branching airway system with 47 orders, whereby order 47 corresponds to the trachea. Each branch is terminated with a viscoelastic tissue unit and there are in total 150,077 acini for the whole model. Using this model, atelectasis of alveoli was simulated by reducing the diameter of small airways (order 1, 2 and 3) up to 90% of their original sizes. The tissue damping factor G was 104 times higher in the collapsed alveoli than that in normal alveoli. The shunt gas compression compliance Cg for the alveolus was 106 times smaller. Diferent percentages of atelectatic area from 0 to 90% were simulated. Flow distribution and airway input impedance were calculated at diferent frequencies from 0.1 to 5 Hz. Alveolar pressure diferences were obtained by analyzing the products of low distribution and alveolar input impedance. Results The alveolar pressure Palv reduced as the frequency increased (for both collapsed and open alveoli). Compared with the situation at 0.2 Hz, Palv reduced to 9.1 ± 1.0% at 4 Hz. On the other hand, Palv increased as the percentage of atelectatic area increased (for all frequencies). Palv increased to 267 ± 6% when 70% of alveoli collapsed compared with 10% of collapse. The pressure diferences between collapsed and open alveoli increased as the frequency increased. At 0.2 Hz the diferences were <3%, while at 4 Hz the diferences were >20% (relative to the lower value). Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Conclusions Increasing the high-frequency contents of the inspiratory low pattern may help to develop a pressure diference between collapsed and open alveoli. The low-frequency contents of the low pattern, however, may be still needed to guarantee the minimum ventilation. Reference 1. Horsield K, et al.: J Appl Physiol 1982, 52:21-26. P188 Decreasing tidal volume from 6 to 4 ml/kg: feasibility and efects on repeated opening and closing J Retamal, J Libuy, M Jimenez, M Delgado, C Besa, G Bugedo, A Bruhn Pontiicia Universidad Católica de Chile, Santiago, Chile Critical Care 2010, 14(Suppl 1):P188 (doi: 10.1186/cc8420) Introduction Low tidal volumes (Vt) are thought to protect the lung by avoiding overdistension. We recently have shown that Vt may also inluence repeated opening and closing (O/C) [1]. The goal of this study was to determine whether decreasing Vt from 6 to 4 ml/kg was efective to reduce O/C, and whether it was possible to maintain alveolar ventilation at such low Vt. Methods Cross-over study at two Vt levels: 6 versus 4 ml/kg IBW. We included ALI/ARDS patients, ventilated <48 hours, and who would have a chest computed tomography (CT) scan. For the 4 ml/kg arm: we replaced the heat and moisture exchange ilter by a heated humidiier, and the respiratory rate was increased to keep minute ventilation constant. The protocol had two parts: one bedside and other in the CT room. Both Vts were applied in a random order. For the bedside protocol each Vt arm was applied for 30 minutes. Data on lung mechanics and gas exchange were taken at baseline and 30 minutes. For the CT scan protocol each Vt arm was applied for 5 minutes and then a dynamic CT (4 images/second for 8 seconds) was taken at each Vt at a ixed transverse region at the lower third of the lungs. Afterwards, CT images were analyzed by software (MALUNA) and repeated O/C was determined as nonaerated tissue variation between inspiration and expiration, expressed as a percentage of lung tissue weight. Results We analyzed nine patients (six male), who had a median age of 39 (21 to 72) years, APACHE II score 14 (5 to 23) and SOFA score 9 (6 to 15). All patients had a pulmonary origin of their ARDS and were on their irst day of ventilation. At baseline patients had a PaO2/FiO2 ratio of 141 (71 to 280), compliance of 32 (17 to 43) ml/cmH2O, and PEEP of 12 (10 to 16) cmH2O. In the Vt arms 4 and 6 ml/kg, Vts were 260 (210 to 300) and 350 (310 to 400) ml, respectively (P <0.01), respiratory rates were 37 (31 to 42) and 25 (21 to 28) breaths per minute (P <0.01), and PaO2 levels were 84 (54 to 148) and 83 (61 to 162) mmHg (P = 0.3). PEEP and FiO2 were kept constant. PaCO2 did not signiicantly increase with Vt 4 but repeated O/C (delta nonaerated tissue) consistently decreased (Figure 1). Conclusions Decreasing Vt from 6 to 4 ml/kg reduces repeated O/C. Hypercapnia can be efectively prevented by decreasing the instrumental dead space and increasing the respiratory rate. Acknowledgements Grant was Fondecyt 11060350. Reference 1. Bruhn A, et al.: Intensive Care Med 2009, 35(Suppl 1):S227. Figure 1 (abstract P188). S66 P189 Barriers to providing lung-protective ventilation to patients with ALI/ARDS RH Passos, RH Oliveira, MQ Trabuco, RR Rodrigues, SP Souza, PB Batista Hospital São Rafael, Salvador, Brazil Critical Care 2010, 14(Suppl 1):P189 (doi: 10.1186/cc8421) Introduction Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are associated with signiicant morbidity and mortality. Mechanical ventilation is the cornerstone of supportive therapy. However, the optimal strategy of ventilation and adjunctive therapies are still evolving. There is evidence to support the use of volume-limited and pressure-limited lung-protective ventilation but practice variability in the clinical management is still a concern mainly in sicker patients. The purpose of this study was to examine the ventilatory prescriptions of clinicians caring for patients with ALI/ARDS. Methods We prospectively examined demographic characteristics, APACHE II score and choice of ventilatory settings at the day of diagnosis of ALI/ARDS (AECC criteria) of 84 mechanically ventilated patients from May 2007 through October 2009 in a mixed medical–surgical critical care unit. Results ALI/ARDS occurred in 7.1% of admissions and 16.1% of all mechanically ventilated patients. Sepsis was the main cause. All patients were ventilated with pressure control mode. Median tidal volume/ predicted body weight was 6.1 (3.5 to 9.9) ml/kg, plateau pressure was 26 (15 to 55) cmH2O and mean PEEP was 12 (5 to 25) cmH2O. Univariate analysis showed sepsis-related ALI/ARDS (P = 0.026) and APACHE II score >18 (P <0.001) were barriers to initiate lung-protective ventilation. In multivariate analysis, APACHE score >18 was an independent predictor. Ventilatory settings were signiicantly diferent in this subset of patients (n = 26). The tidal volume/predicted body weight (6.2 (3.5 to 9.9) vs 5.1 (4.3 to 8.5) ml/kg), PEEP (15 (10 to 25) vs 7 (6 to 12) cmH2O) and plateau pressure (38 (32 to 55) vs 22 (15 to 30) cmH2O) were higher in the group with APACHE II score >18 (P <0.001). PaO2/FiO2 pH and paCO2 did not difer between groups. As expected, mortality was higher in this group, 60% vs 22% (P <0.001). Conclusions Protective mechanical ventilation is not completely feasible in the subset of ALI/ARDS patients with higher risk of mortality (APACHE II >18). Reference 1. Acute Respiratory Distress Syndrome Network: Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000, 342:1301. P190 Inluence of aetiology of acute respiratory distress syndrome and early diferences in oxygenation on outcome M Shankar-Hari1, CI Olvera2, S Webb2, S Phelps2, S Batson2, A Puddicome2, R Marshall2, D Howell2, G Bellingan2 1 Guy’s and St Thomas’ NHS Foundation Trust, London, UK; 2University College Hospital, London, UK Critical Care 2010, 14(Suppl 1):P190 (doi: 10.1186/cc8422) Introduction Studies evaluating the relationship between the severity of hypoxemia in patients with acute respiratory distress syndrome (ARDS) Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 and hospital outcome have not found a consistent outcome association. We hypothesized that severity of hypoxemia on admission after optimal ventilation may predict hospital outcome if the ARDS patients are categorised based on the primary etiology: pulmonary ARDS (ARDSp) and extra pulmonary ARDS (ARDSexp). Our aim was therefore to ascertain the relationship between hospital outcome and the severity of hypoxemia in patients with early ARDS (days 1 to 3 following admission) after categorising based on etiology. Methods We used a prospective cohort study design and enrolled 151 consecutive patients with a primary diagnosis of ARDS on the day of admission, admitted over a 2-year period to our adult general ICU. Patients enrolled in other clinical interventional trials were excluded from the study. Protocol-based management of mechanical ventilation was used to achieve optimal ventilation. Two authors independently designated patients as ARDSp or ARDSexp and a third reviewed any conlicts (only four cases). Patients were then subcategorised by severity of hypoxaemia based on PaO2/FiO2 ratio (P/F ratio) intervals. All other clinical interventions were at the discretion of treating clinician. Results The hospital mortality in all patients included in the study (n = 151) with ARDS was 44.1%. The patients classiied as ARDSp had a higher hospital mortality (50.6%) compared with ARDSexp (36.4%), but the diference was not statistically signiicant (P = 0.12). Nonsurvivors with ARDSp had a signiicantly lower P/F ratio on day 1 of ARDS diagnosis compared with survivors (12.05 ± 4.46 vs 15.39 ± 4.97 kPa; P = 0.002), a relationship not observed with ARDSexp. This association between mortality and hypoxaemia in early ARDSp persisted at even more serve levels of hypoxaemia (<15 kPa, <12.5 kPa, and <10 kPa; P = 0.01, P = 0.003 and P = 0.002, respectively), while in ARDSexp the efect of hypoxaemia on mortality was not observed. Conclusions Our indings indicate that the hypoxaemia burden as assessed by P/F ratio intervals despite optimal ventilatory support on the day of ICU admission predicts increased risk of death in ARDSp; but not in ARDSexp. Interventional trials need to account for the inluence of etiology and hypoxaemia burden on outcome prior to concluding this as a negative intervention. P191 Acute lung injury in TBI patients with SIRS: role of vascular endothelial damage T Saito1, H Kushi2, T Miki1, J Sato1, A Yoshino1, K Tanjo1 1 Nihon University, School of Medicine, Tokyo, Japan; 2Nihon University, College of Humanities and Sciences, Tokyo, Japan Critical Care 2010, 14(Suppl 1):P191 (doi: 10.1186/cc8423) Introduction The pathological organ dysfunction that occurs in patients with SIRS or sepsis is believed to be related to vascular endothelial damage. We investigated the role of vascular endothelial damage in the occurrence of acute lung injury in severe TBI patients with SIRS. Methods The subjects were 20 severe TBI patients with SIRS. The P/F ratio was calculated from arterial blood gas analysis data obtained for seven consecutive days from the time of admission. Peripheral blood samples were collected four times to measure the serum levels of IL-6 and IL-8, and the levels of ICAM-1 and granulocyte elastase (GE) as markers of vascular endothelial damage. Results The P/F ratio decreased with time and was below 300 from day 4 onwards. However, the survivors maintained a P/F ratio of 300 or more. In the patients with a fatal outcome, the ratio continued to decline and the subjects developed acute lung injury on day 3. From day 5 onward, they showed a signiicant decrease of the ratio, with values of 200 or less and symptoms of adult respiratory distress syndrome. The levels of IL-6, IL-8, ICAM-1, and GE increased after admission, but then decreased again in the survivors. In the patients who died, these levels continued to rise and there was a signiicant increase of IL-6, IL-8, and ICAM-1 after 1 week. The correlation between the blood level of IL-6 and the level of IL-8, ICAM-1, or GE was strong, while that between the IL-8 level and the ICAM-1 or GE levels was also strong and that between the ICAM-1 and GE level was weaker. In contrast, the correlations between the P/F ratio and the blood levels of IL-6, IL-8, ICAM-1, or GE were moderate and negative. Therefore, inverse correlations were noted between the P/F ratio and all these parameters. S67 Conclusions By determining the changes of humoral mediators, we demonstrated that vascular endothelial damage was involved in the occurrence of the pathological state of acute lung injury, which occurs in severe TBI patients with SIRS. P192 Mechanical ventilation aggravates transfusion-related acute lung injury induced by MHC class I antibodies AP Vlaar1, EK Wolthuis1, JJ Hofstra1, JJ Roelofs1, L Boon2, MJ Schultz1, R Lutter1, NP Jufermans1 1 Academic Medical Center, Amsterdam, the Netherlands; 2Bioceros, Utrecht, the Netherlands Critical Care 2010, 14(Suppl 1):P192 (doi: 10.1186/cc8424) Introduction Transfusion-related acute lung injury (TRALI) occurs more often in critically ill patients than in a general hospital population, possibly due to the presence of underlying inlammatory conditions that may prime pulmonary neutrophils. Mechanical ventilation (MV) may be a risk factor for developing TRALI. We determined the inluence of MV on the development of TRALI, combining a murine MV model causing ventilatorinduced lung injury with a model of antibody-induced TRALI [1,2]. Methods BALB/c mice (n = 84) were ventilated for 5 hours with low (7.5 ml/kg) or high (15 ml/kg) tidal volume, a positive end-expiratory pressure of 2 cmH2O and a fraction of inspired oxygen of 50%. After 3 hours of MV, TRALI was induced by infusion of MHC-I antibodies (4.5 mg/ kg), controls received vehicle. Nonventilated animals receiving vehicle, isotype or MHC-I antibodies served as additional controls. Results All animals receiving MHC-I antibodies developed TRALI within 2 hours. In mice in which TRALI was induced, MV with low tidal volumes aggravated pulmonary injury as evidenced by an increase in neutrophil inlux, pulmonary and systemic levels of cytokines and lung histopathological changes compared with unventilated controls. The use of high tidal volume ventilation resulted in a further increase in protein leakage and pulmonary edema. Conclusions MV synergistically augmented lung injury during TRALI, which was even further enhanced by the use of injurious ventilator settings. Results suggest that MV may be a risk factor for the onset of TRALI and may aggravate the course of disease. References 1. 2. Wolthuis EK, Vlaar AP, Choi G, et al.: Mechanical ventilation using noninjurious ventilation settings causes lung injury in the absence of preexisting lung injury in healthy mice. Crit Care 2009, 13:R1. Looney MR, Su X, Van Zile JA, et al.: Neutrophils and their Fcγ receptors are essential in a mouse model of transfusion-related acute lung injury. J Clin Invest 2006, 116:1615-1623. P193 Adaptive support ventilation may be inappropriate for patients with ALI/ARDS after recruitment: an observational study F Paulus, DA Dongelmans, DP Veelo, JM Binnekade, MJ Schultz Academic Medical Center, Amsterdam, the Netherlands Critical Care 2010, 14(Suppl 1):P193 (doi: 10.1186/cc8425) Introduction With adaptive support ventilation (ASV), a microprocessorcontrolled mode of mechanical ventilation, the ventilator adapts tidal volume (VT) size based on the Otis least work of breathing formula. In recent studies in patients with ALI/ARDS, ASV applied VT of 7.3 (6.7 to 8.8) ml/kg ideal body weight (IBW). It is unclear whether an open–lung approach was used in these studies. Lung recruitment improves lung compliance, and as a consequence may allow the ventilator to apply too large a VT with ASV. Methods Ten consecutive patients with ALI/ARDS, ventilated in accordance with our local protocol dictating frequent recruitment maneuvers, were observed while the ventilator was switched from pressure control ventilation (PC) to ASV. Thereafter, all patients were subjected to an additional standard recruitment procedure. The primary endpoint was VT before and after switch of the ventilator, and after standard recruitment. Results Four patients sufered from ALI, six patients from ARDS. Seven patients had an extrapulmonary cause for ALI/ARDS. VT increased from 6.5 ± 0.8 ml/kg IBW to 9.0 ± 1.6 ml/kg IBW (P <0.01) after switch from PC Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 to ASV. Additional recruitment after switch of the ventilator did not afect VT size (9.3 ± 1.4 ml/kg IBW, P >0.05). In seven patients ASV applied VT >8 ml/kg IBW, in one patient VT even increased to >12 ml/kg IBW. Conclusions Patients with ALI/ARDS may be ventilated with too large a VT when subjected to ASV. Our results contrast indings of previous studies on ASV in patients with ALI/ARDS, probably because we frequently use recruitment maneuvers. P194 Receptor for advanced glycation end products is associated with systemic and organ-speciic severity of acute lung injury and acute respiratory distress syndrome A Pradella1, T Mauri1, S Masson2, G Bellani1, A Coppadoro1, F Magni1, M Bombino1, N Patroniti1, R Latini2, A Pesenti1 1 San Gerardo Hospital and University of Milan-Bicocca, Monza, Italy; 2Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy Critical Care 2010, 14(Suppl 1):P194 (doi: 10.1186/cc8426) Introduction Receptor for advanced glycation end products (RAGE) is an acute phase inlammatory mediator primarily expressed by alveolar type I cells in the lung. The association between circulating RAGE and severity of acute lung injury and acute respiratory distress syndrome (ALI/ARDS) has been recently suggested by both experimental and human studies. The purpose of our study is to study the signiicance of plasma RAGE levels over time and of bronchoalveolar lavage luid (BALf ) RAGE in ALI/ARDS patients. Methods We enrolled 21 patients admitted to a single general ICU of a university-ailiated hospital afected by ALI/ARDS (1994 Consensus Conference criteria). We measured plasma RAGE levels twice on the irst 2 days from intubation, then every 3 days for the irst month and then once a week, until ICU discharge or death (n = 188). We also measured RAGE levels in BALf obtained by means of a standardized technique when clinically indicated (n = 22). At each sampling time we recorded data on ventilator settings, gas exchange, organ function and blood cell counts. Results Day 1 plasma RAGE levels (normal values <170 pg/ml) were high (median 1,588 pg/ml, IQR 780 to 2,398 pg/ml) and then lowered over time. When all samples were considered, plasma RAGE levels were signiicantly higher in patients with blood platelet count <100 x 103/μl, with plasma creatinine level ≥2 mg/dl and with SOFA score ≥5 (P = 0.029, P = 0.001 and P = 0.045, respectively). Plasma RAGE increased also with the number of organ failures (P = 0.004). Moreover, circulating RAGE was signiicantly higher in patients with PaO2/FiO2 <150 and with PEEP ≥10 cmH2O (P = 0.045 and P <0.001, respectively). RAGE was present in BALf (median 174 pg/ml, IQR 46 to 1,476 pg/ml). Interestingly, plasma and BALf RAGE levels were not correlated (P = 0.2). BALf RAGE was signiicantly higher in patients with PaO2/FiO2 <150 mmHg and with administered tidal volume:ideal body weight ratio >6 ml/kg (P = 0.021 and P = 0.009, respectively). Patients with culture-positive BALf had higher BALf RAGE levels in comparison with culture-negative BALf (P = 0.014). Figure 2 (abstract P195). S68 Conclusions In ALI/ARDS patients, circulating RAGE is high on day 1, decreases over time and may be related to systemic and lung injury severity. BALf RAGE obtained from these patients may be associated with lung dysfunction and infection. P195 Mild hypothermia was protective in a physiological model of ventilator-induced lung injury by reducing inlammation but not by reducing the respiratory rate H Aslami, M Schultz, N Jufermans Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam, the Netherlands Critical Care 2010, 14(Suppl 1):P195 (doi: 10.1186/cc8427) Introduction In animal models of ventilator-induced lung injury (VILI), mild hypothermia was found to be protective by reducing pulmonary inlammation and possibly by reducing mechanical strain by applying lower respiratory rates. However, models are hampered by severe alkalosis or an ex vivo design. In a physiological model of VILI, we investigated whether hypothermia protects from VILI by reducing respiratory rates, or by reducing inlammation. Methods In rats, VILI was induced using a peak inspiratory pressure (PIP) of 23 cmH2O and zero PEEP. Controls were ventilated with a PIP of 12 cmH2O and PEEP of 5 cmH2O. Hypothermia (32ºC) was induced by external cooling, controls were maintained at 37ºC. Normo-pH (7.3 to 7.4) or strict normocapnia (4.5 to 5.0 kPa) was achieved by adjusting the respiratory rate according to blood gases drawn every 30 minutes. After 4 hours of Figure 1 (abstract P195). Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 ventilation, bronchoalveolar lavage (BAL) was done. Statistics include Kruskal–Wallis and Mann–Whitney U tests. Results A physiological model of VILI was established. In the normo-pH group, hypothermia decreased pulmonary IL-6 and neutrophil inlux and tended to decrease pulmonary protein leak (Figure 1). In the normocapnia group, hypothermia allowed for lower respiratory rates compared with normo-pH (11 ± 1 vs 17 ± 2 breaths/minute) (Figure 2). However, this did not further reduce parameters of lung injury. Conclusions Hypothermia was protective in a physiological model of VILI, by reduction of inlammation, but not by reducing the repetitive strain of respiratory cycles. P196 Efect of induced hypothermia on respiratory parameters in mechanically ventilated patients H Aslami, J Binnekade, S Huissoon, N Jufermans Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam, the Netherlands Critical Care 2010, 14(Suppl 1):P196 (doi: 10.1186/cc8428) Introduction Therapeutic hypothermia is applied to reduce hypoxiainduced organ injury. In the past decades, the use of hypothermia has increased in critically ill patients who are mechanically ventilated (MV). Data on the efect of hypothermia on gas exchange and lung mechanics in these patients are limited. In this retrospective study, we describe the efect of induced hypothermia and rewarming on respiratory parameters in patients after a cardiac arrest. Methods Patients with a Glasgow Coma Scale <8 after resuscitation for a cardiac arrest in whom hypothermia was applied (32 to 34°C), were enrolled. Patients with PaO2/FiO2 ratio <200 or MV with positive endexpiratory pressure (PEEP) >15 cmH2O were excluded. Ventilator settings and arterial blood gasses were retrieved from the electronic patient database during hypothermia and at every °C grade increase during rewarming. Statistics include z paired t test. Results From a cohort of 98 patients, 35 patients were excluded, leaving 62 patients for analysis. During hypothermia, arterial pCO2 decreased, while end tidal (et) CO2 was low at unchanged minute volume ventilation (Figure 1). Hypothermia increased the P/F ratio from 255 ± 55 to 283 ± 12 at unchanged PEEP (P <0.05), while luid balances were positive in all patients (2.5 ± 1.6 l). After rewarming, arterial pCO2 was unchanged while etCO2 increased. The P/F ratio after rewarming was unchanged compared with the start of hypothermia, while lower PEEP levels were applied (7.0 ± 0.4 cmH2O vs 6.1 ± 0.3 cmH2O, P <0.05). Conclusions Induced hypothermia improved ventilation and oxygenation in critically ill patients. Hypothermia may be considered in patients with acute lung injury, in whom low minute ventilation results in severe hypercapnia. Figure 1 (abstract P196). S69 P197 Extracorporeal life support service in a regional referral center: the Florence experience S Biondi1, A Pasquini2, S Batacchi2, G Cianchi2, M Ciapetti2, S Di Valvasone1, S Bacci2, L Varegliano2, M Solaro2, M Bonizzoli2, R Spina2, M Bonacchi3, G Zagli2, C Nozzoli2, A Peris2, GF Gensini3 1 Postgraduate School of Anesthesia and Intensive Care, University of Florence, Italy; 2Careggi Teaching Hospital, Florence, Italy; 3University of Florence, Italy Critical Care 2010, 14(Suppl 1):P197 (doi: 10.1186/cc8429) Introduction Extracorporeal life support (ECLS) represents a therapeutic choice in cases of acute reversible lung and/or heart failure. An emergency ICU can safely manage both veno-arterial (V-A) and veno-venous (V-V) ECLS. Methods In our experience, the ECLS treatment implementation started on April 2008. The ECLS team is composed of intensivists, cardiac surgeons, cardiologists, perfusionists and nurses. All of these igures were trained in ECLS management. An Emergency Medical Service has been equipped to guarantee rapid and safe ECLS positioning in peripheral hospitals and transportation to our referral center by the ECLS team. According to our internal protocol, eligible patients for V-V ECLS treatment are aged 15 to 70 years old and afected by ARDS with a PaO2/FiO2 ratio <60 or pH <7.20, under a protective ventilation setting. The use of ECLS for cardiac support is reserved for those cases of cardiac shock refractory to standard treatments and cardiac arrest not responding to advanced cardiac life support (ACLS). The ECLS device used is a Rotalow Maquet Centrifugal Pump with a Quadrox-D oxygenator (Maquet, Rastatt, Germany) and biocoated circuits. Results From April 2008 to November 2009, 21 patients were treated with ECLS. In 13 patients V-V ECLS was established due to severe ARDS not responding to conventional treatment. Median SAPS II at admission was 49 and median duration was 235 hours. Three out of 13 patients were cannulated by the ECLS team in peripheral hospitals and safety transported. The intra-ICU survival rate was 62%. ECLS for cardiac support was performed in eight patients: four cases of intrahospital cardiac arrest, four cases of cardiogenic shock. Median stay of V-A ECLS was 110 hours. In cases of V-A ECLS due to cardiac arrest, no positive outcome was observed. The median stay of ACLS maneuvers before ECLS start was 62.5 minutes In cases of cardiogenic shock undergoing ECLS, two out of four patients were discharged from our ICU. Conclusions A complete competence acquisition for ECLS management makes this system a safe and feasible technique. The possibility to guarantee a safe treatment must involve diferent specialists and properly trained nurses. We found the importance of a well-timed start of ECLS. P198 Interhospital ground transportation of severe acute respiratory distress syndrome patients on extracorporeal membrane oxygenation: Monza’s experience S Isgro1, M Milan1, A Zanella1, M Bombino1, G Foti1, M Giani1, S Abd El Aziz El Sayed Deab1, N Patroniti2, A Pesenti2 1 AO San Gerardo Monza, Italy; 2Milano-Bicocca University, Milan, Italy Critical Care 2010, 14(Suppl 1):P198 (doi: 10.1186/cc8430) Introduction Severe acute respiratory distress syndrome (ARDS) patient transportation is an extremely high-risk procedure. We report our experience in transferring these patients to our centre while on extracorporeal membrane oxygenation (ECMO). Methods After telephone referral and bed availability conirmation, patients matching entry criteria for ECMO are evaluated for transportation to our centre. A skilled crew consisting of two expert plus one training physician, one expert plus one training ICU nurse and one ECMO specialist reaches the referral hospital for re-evaluation. If eligible, cannulation, ECLS circuit set up and ECLS start are accomplished. Ground transport is performed with a specially equipped ambulance, endowing enlarged oxygen, fuel and energy supplies. The ambulance is loaded with all of the items required for cannulation and ECMO circuit set up, additional oxygen and a nitric oxide tank. Entry criteria are: potentially reversible respiratory failure, Murray Score ≥3 or respiratory acidosis with pH <7.2, no intracranial bleeding and absolute contraindication to heparinization. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Results Between 2004 and 2009 our crew evaluated for transfer on ECMO 15 ARDS patients (10 males), age 38 ± 15 years, BMI 28 ± 7, APACHE II score 26 ± 9, SOFA score 9 ± 4, Oxygenation Index 39 ± 17. The average distance was 133 ± 124 km. Two patients improved after NO trial and were transferred without ECMO. All of the other patients underwent venovenous ECMO: 11 with cannulation of femoral veins, one femoral–jugular veins and one with a DL cannula in the jugular vein. ECMO settings were (mean ± SD) BF 2.9 ± 0.8, GF 3.6 ± 1.6, GF FiO2 1. Data have been recorded 30 minutes before and 1 hour after ECLS began: vv-ECMO granted a better clearance of pCO2 (75 ± 20.5 vs 49.7 ± 7.9 mmHg, P <0.01), thus improving the pH (7.279 ± 0.10 vs 7.41 ± 0.06, P <0.01) and mean pulmonary arterial pressure (41 ± 11 vs 31 ± 5 mmHg, P <0.05) and allowing a reduction in respiratory rate (28 ± 11 vs 9 ± 4, P <0.01), minute ventilation (10.2 ± 4.6 vs 3.3 ± 1.7 l/min, P <0.01) and mean airway pressure (26 ± 6 vs 22 ± 5 cmH2O, P <0.01). Arterial pO2, mean blood pressure and heart rate did not show signiicant variations. After ECMO began, vasoconstrictor therapy (being administered to ive patients) was quickly tapered. Neither clinical nor technical major complications were reported. Conclusions ECMO employment at referral centers enabled longdistance, high-risk ground transportation. P199 Efects of hypertonic saline on a pig model of acute lung injury induced by hydrochloric acid instillation CA Holms1, DA Otsuki1, M Kahvegian1, J Noel-Morgan1, C Massoco2, DT Fantoni1, P Gutierrez3, JO Auler Jr1 1 Faculdade de Medicina da Universidade de São Paulo, Brazil; 2Genoa, São Paulo, Brazil; 3INCOR, São Paulo, Brazil Critical Care 2010, 14(Suppl 1):P199 (doi: 10.1186/cc8431) Introduction Controversy exists over the possible beneicial efects of hypertonic saline (HS) in pulmonary inlammatory response, particularly in neutrophil immunomodulation [1,2]. This study was designed to investigate possible beneits of HS in the treatment of pigs submitted to experimental acute lung injury. Methods Twelve anesthetized, tracheotomized pigs (25 to 30 kg) were mechanically ventilated by pressure, adjusted to 8 ml/kg tidal volume, with FiO2 50%, and submitted to intratracheal instillation of 4 ml/kg hydrochloric acid (HCl) 0.1 N. They were then randomized to ALI group (n = 7) or ALI + HS group (n = 5), where animals of the latter group received 4 ml/kg intravenous hypertonic saline, 15 minutes after injury. Hemodynamic parameters, pulmonary compliance (Cstat), peak pressure (Ppeak), plateau pressure (Pplat) and tidal volume (Vt) were analyzed at baseline (TBL), 15 minutes after HCl instillation (TALI) and hourly thereafter for 4 hours (T0 to T3). Bronchoalveolar lavage was performed at the end of the observation period for low cytometry analysis of neutrophil burst activity. Postmortem histopathology of the right diaphragmatic lung was also performed in all animals. Results After TALI, animals of both groups presented signiicant increases in Ppeak and Pplat, and a decrease in Cstat, at all time points, when compared with TBL. Vt was preserved in both groups over time. There were signiicant diferences between groups ALI and ALI + HS, respectively, in: central venous pressure (T0, T1 and T2), pulmonary artery occlusion pressure (T1 and T2) and pulmonary vascular resistance index (TALI). In the ALI group, signiicant diferences related to TBL were found in mean arterial pressure (T1), mean pulmonary artery pressure (TALI, T0, T1, T2 and T3) and pulmonary vascular resistance index (TALI, T0, T3). In the ALI + HS group, there were signiicant diferences related to TBL in mean arterial pressure (T0, T1, T2), mean pulmonary artery pressure (TALI, T0, T1, T2, T3), cardiac index (T0, T1, T2) and pulmonary vascular resistance index (T1, T2, T3). No diferences were found between groups regarding histopathology and low cytometry analyses. Conclusions HS produced no signiicant beneit in the studied parameters regarding the lungs, in the proposed model of ALI. Acknowledgements Grants from FAPESP 08/55376-7 and 08/56792-4. References 1. 2. Roch A et al.: Intensive Care Med 2007, 33:1645-1654. Deree J et al.: J Trauma 2007, 62:104-111. S70 P200 Conventional mechanical ventilation can injury intact lungs in severe trauma patients O Ignatenko, D Protsenko, A Yaroshetskiy, B Gelfand State Medical Unversity of Russia, Moscow, Russia Federation Critical Care 2010, 14(Suppl 1):P200 (doi: 10.1186/cc8432) Introduction Conventional mechanical ventilation (MV) may cause additional lung injury in ALI/ARDS due to overdistention of aerated lung regions (high Vt) and cyclic lung reopening (low PEEP level). Hyperproduction of inlammatory mediators is one of the side efects in these cases. This factor could delay or prevent resolution of respiratory failure [1,2]. However, it is not clear whether conventional mechanical ventilation damages intact lungs. The aim of this study was to evaluate the efects of conventional and protective mechanical ventilation on intact lungs in patients with severe trauma. Methods A prospective, randomized controlled trial in trauma patients with mechanical ventilation for extrapulmonary indications. The protocol was approved by the local ethics committee. Seventy-eight patients were randomized to conventional (Vt 10 to 12 ml/kg IBW, PEEP 5 cmH2O – n = 39) or protective (Vt 5 to 6 ml/kg IBW, PEEP 10 cmH2O – n = 39) mechanical ventilation. TNFα, IL-1β and IL-6 levels in plasma and BAL luids were measured on 1, 2, 3, 5 and 7 days of MV. Frequency of ALI (AECC criteria) and VAP were evaluated. The endpoints of this study were the length of MV, LOS in ICU and outcome on 28 days. Results In irst 3 days ALI was revealed in 26 patients (66.6%) in the conventional and 10 patients (26.5%) in the protective MV groups (P = 0.001; OR 4.375, 95% CI 2.227 to 8.189). ARDS occurred in four patients (10,2%) of the conventional MV group (LIS >2) and no one in the protective MV group (P <0.0001). Levels of TNFα, IL-1β and IL-6 in BAL luids were signiicantly higher in the conventional MV group from 1 to 7 days with maximal increase on day 3 (542 ± 44/91 ± 11; 315 ± 35/86 ± 10; 1,092 ± 160/111 ± 18, P <0.0001). No diferences were found in levels of TNFα, IL-1β and IL-6 in plasma samples. VAP occurred in 31 patients (83.7%) of the conventional and nine patients (23%) of the protective MV groups (P = 0.0001; OR 17.2, 95% CI 5.5 to 54.3). The length of MV was 17.4 ± 6 vs 12.8 ± 3 (P = 0.0001; OR 4.2, 95% CI 1.5 to 11.5), LOS in the ICU was 21.9 ± 5.6 vs 15.75 ± 2.9 (P = 0.0002; OR 2.0, 95% CI 0.18 to 23.6). The 28-day mortality was not signiicantly diferent in the groups. Conclusions Conventional MV for more than 72 hours in patients with severe trauma and intact lungs can cause lung injury, and increase duration of MV and LOS in the ICU. References 1. 2. Dreyfuss D, Saumon G: Ventilator-induced lung injury: lessons from experimental studies. Am J Respir Crit Care Med 1998, 157:294-323. Parker JC, Hernandez LA, Peevy KJ: Mechanisms of ventilator-induced lung injury. Crit Care Med 1993, 21:131-143. P201 Protective efect of methylprednisolone on ventilator-induced diaphragm dysfunction is dose dependent K Maes1, A Agten1, A Smuder2, SK Powers2, M Decramer1, G Gayan-Ramirez1 1 KU Leuven, Belgium; 2University of Florida, Gainesville, FL, USA Critical Care 2010, 14(Suppl 1):P201 (doi: 10.1186/cc8433) Introduction Administration of 80 mg/kg methylprednisolone has been shown to prevent controlled mechanical ventilation (CMV) diaphragm dysfunction in rats, partly by inhibiting the calpain system [1]. The current experiments determined whether lower doses of corticosteroids will also provide protection against ventilator-induced diaphragm dysfunction. Methods Rats were assigned to a control group or to 24 hours of CMV receiving a single injection of saline or 5 mg/kg (low MP) or 30 mg/kg (high MP) of methylprednisolone. Results Diaphragm force production was decreased after CMV but signiicantly more in the low MP group while similar to controls in the high MP group. Atrophy of the type IIa ibers was only present in the low MP group. Atrophy of the type IIx/b ibers was more severe in the low MP group than in the CMV group while no atrophy was observed in the high MP group. Diaphragm calpain activity was increased after CMV (+93%, P <0.05 vs C) and in the low MP group (+83%, P <0.05 vs C), while it was similar to controls in the high MP group. Expression of calpastatin was Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 decreased in the CMV and the low MP group (–18%, P <0.05 vs C) but its level was preserved to control levels in the high MP group. Analysis of the caspase-3 mediated cleavage of αII-spectrin revealed that CMV induced a signiicant rise in caspase-3 activity when compared with C (+194%, P <0.001). Caspase-3 activity was similarly increased in the MP-5 and the MP-30 groups (+96% and +78% respectively, P <0.05 vs C) but this increase was signiicantly less compared with that of CMV. Signiicant negative correlations were found between calpain activity and diaphragm force (–0.50 <r <–0.41, P <0.05) as well as with CSA of the type IIx/b ibers (r = –0.57, P <0.02). Signiicant positive correlations were observed between calpastatin and diaphragm force (0.43 <r <0.54, P <0.05) and calpastatin and CSA of the type IIx/b ibers (r = 0.57, P <0.02). Conclusions The ability of corticosteroids to protect against CMV-induced diaphragmatic contractile dysfunction and atrophy are dose dependent with only high doses of corticosteroids providing protection. Acknowledgements Supported by Astra Zeneca Pharmaceuticals and FWO Vlaanderen. Reference 1. Maes et al.: Am J Respir Crit Care Med 2008, 178:1219-1226. P202 Alveolar recruitment with non-invasive mechanical ventilation (C-PAP) in patients with nonobstructive respiratory failure V Tomicic1, R Moreno1, V Hidalgo1, P Vargas1, J Keymer1, A Fuentealba1, G Hormazabal1, R Perez1, J Molina1, J Borges2 1 Clinica Alemana de Santiago, Chile; 2University of São Paulo, Brazil Critical Care 2010, 14(Suppl 1):P202 (doi: 10.1186/cc8434) Introduction Non-invasive mechanical ventilation (NIMV) is able to reduce reintubation especially in patients with exacerbation of COPD. Results have not been reached in critically ill patients with nonobstructive respiratory failure (NORF). However, the NIMV in most of these studies has been applied without making an efort to open the lung and adjusting the C-PAP after opening up the lung using a clinical approach. Our aim was to evaluate the efects of applying recruitment manoeuvres (RM) with C-PAP and titrate it according to clinical decremental C-PAP trial in patients with NORF. Methods NORF patients for whom NIMV was indicated between January 2008 and July 2009 were included and submitted to the NIMV-RM protocol when a trained team was available. Bi-PAP and a full face mask were used. The inclusion criteria were at least two of the following: respiratory rate (RR) >30, accessory muscle activity, saturation ≤90% with FiO2 ≥50% and consolidation areas on thorax X-ray. Gradual increasing of C-PAP (2 cmH2O) was used from 10 to 20 cmH2O. Each level of C-PAP was sustained for 5 minutes according to tolerance. The C-PAP after RM was adjusted when the maximal tidal volume (VT) was reached, pulse oximetry (PO) did not show any substantial change and when the patient was comfortable. Demographic data, APACHE II score and lung injury score (LIS) were measured. Cardiac rate (CR), RR, arterial pressure (AP), PO, minute ventilation (VE) and percentage of mask leak (PML) were recorded through the RM. Arterial blood gases were measured pre-RM, 1, 12 and 24 hours after RM. Variables are expressed as median (range). ANOVA by repeated measures or Kruskal–Wallis was used, P <0.05 was considered signiicant. Results Fourteen patients were included. Age, APACHE II and LIS were: 56 (17 to 80); 14 (4 to 21) and 2 (1.3 to 2.7). The PaO2/FiO2 ratio increased from 169.1 ± 69.7 (basal) to 261 ± 106 after 1 hour of RM (P = 0.02).Improvement was preserved at 12 and 24 hours, 280 ± 69 and 295 ± 73, respectively. The C-PAP level 1 hour after RM was 14.9 ± 2.4, and 14.1 ± 1.9 at 24 hours post RM. The hemodynamic stability, RR, AP, PML and VE did not change during and after the RM. Conclusions RM with gradual increments of C-PAP is safe. RM in patients with NORF could be an alternative to rescue patients with poor outcome with NIMV alone. P203 N-acetylcysteine attenuates ventilator-induced diaphragm dysfunction in rats A Agten1, K Maes1, A Smuder2, SK Powers2, M Decramer1, G Gayan-Ramirez1 1 KU Leuven, Belgium; 2University of Florida, Gainesville, FL, USA Critical Care 2010, 14(Suppl 1):P203 (doi: 10.1186/cc8435) S71 Introduction Controlled mechanical ventilation (CMV) results in diaphragmatic dysfunction. Oxidative stress is an important contributor to ventilator-induced diaphragm dysfunction, since 18 hours of CMV lead to increased protein oxidation and increased lipid peroxidation. We hypothesized that administration of an antioxidant, N-acetylcysteine (NAC), would restore the redox balance in the diaphragm and prevent the deleterious efects of CMV. Methods Anesthetized rats were submitted for 24 hours to either spontaneous breathing while receiving 150 mg/kg NAC (SBNAC) or saline (SBSAL) or to CMV while receiving 150 mg/kg NAC (MVNAC) or saline (MVSAL). Results After 24 hours, diaphragm forces were signiicantly lower in MVSAL compared with all groups. Administration of NAC completely abolished this decrease such that forces produced in the MVNAC group were comparable with those of both SB groups. Protein oxidation was signiicantly increased in MVSAL (+53%, P <0.01) and was restored in MVNAC. Diaphragm caspase-3 activity was signiicantly increased in MVSAL compared with SBSAL (+279%, P <0.001). Caspase-3 activity was also increased in the MVNAC group (+158.5%, P <0.01) but to a signiicantly lesser extent compared with that of MVSAL. Calpain activity was signiicantly increased after CMV (+137%, P <0.001 vs SBSAL), while it was similar to SB groups in the MVNAC group. Signiicant negative correlation was found between calpain activity and diaphragm tetanic force (r = –0.48, P = 0.02). Conclusions These data show that the administration of NAC was able to preserve the diaphragm from the deleterious efects of CMV. NAC inhibits the increase in oxidative stress and proteolysis and reduces the decrease in force generating capacity of the diaphragm. P204 In vitro muscle contraction force measurements on isolated and entire rat diaphragms C Armbruster, C Dassow, K Gamerdinger, J Guttmann, M Schneider, S Schumann University Medical Center Freiburg, Germany Critical Care 2010, 14(Suppl 1):P204 (doi: 10.1186/cc8436) Introduction Inactivity of the diaphragmatic muscles during mechanical ventilation leads to atrophy and contractile dysfunction. Up to now, in vitro force measurements were performed only on single diaphragmatic muscle strips. Our intention was to ind out how mechanical and electrical stimulation inluences the condition of the diaphragm as a whole organ. To determine the status of the diaphragm, muscle contraction forces were measured on entire rat diaphragms. Methods We used an earlier described bioreactor [1] as the cultivation and measurement device for the whole rat diaphragm. The bioreactor consists of a pressure chamber and a supply chamber that are separated by a very lexible and soft membrane [2]. On this membrane the sample diaphragm is placed. By application of certain gas volumes (0 to 1.5 ml) in the pressure chamber, diaphragms are delected to various levels of pretension. Diaphragms were electrically stimulated at each delection level 10 times (750 ms duty cycle, 100 ms stimulation time, 5 ms pulse width, 200 Hz frequency). Pressure changes caused by muscle contraction were recorded inside the pressure chamber and muscle contraction forces were calculated. After initial force measurements, diaphragms were exposed for 6 hours to one of four diferent treatments: nonstimulated storage (control), cyclic mechanical delection, electrical stimulation every 20 minutes, combination of cyclic delection and electrical stimulation. After 6 hours another force measurement was performed. Supernatants were collected after 6 hours and investigated for IL-6 activity. Results Depending on the level of delection of the diaphragms, muscle contraction force increased from 0.1 N (volume 0.6 ml) to 0.7 N (volume 1.5 ml). A larger pretension of the diaphragm resulted in larger muscle contraction force. After treatment, muscle contraction force decreased in all groups. Muscle contraction force was smallest in the passive control group (0.05 N), larger and similar in the electrically stimulated (0.1 N) and combination (0.09 N) groups and largest in the mechanically delected group (0.15 N). IL-6 activity increased after 6 hours of treatment. Conclusions We conclude that it is possible to perform force measurements on whole rat diaphragms in our in vitro model. Additionally, the diaphragms can kept alive for >6 hours to apply diferent stimulation Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 treatments. The diaphragmatic muscle force generation depends on the pretension level of the diaphragm as well as on the treatment history. References 1. 2. Schumann et al.: J Biomed Mater Res B Appl Biomater 2008, 86B:483-492. Armbruster et al.: J Biomed Mater Res B Appl Biomater 2009, 91:700-705. P205 Useful of implementation of neurally adjusted ventilatory assist in critically ill patients MJ Sucre, A De Nicola San Leonardo Hospital, Castellamamre di Stabia, Italy Critical Care 2010, 14(Suppl 1):P205 (doi: 10.1186/cc8437) Introduction Neurally adjusted ventilatory assist (NAVA) is a new mode of assisted mechanical ventilation that uses the signal obtained from electromyography activity of the diaphragm (EAdi) to control the mechanical ventilator that delivers assist in proportion to the patient’s respiratory drive. This study evaluated the monitoring Edi on conventional mode response, during the switch to pressure support assist and during the change to NAVA: a mode of predicting weaning from ventilation. Methods Sixteen adult patients ventilated with SERVO-I (Maquet) on pressure control or Bivent were randomized; we placed the specialized naso/orogastric tube (Edi catheter) and watched the Edi signal. PSV was set to obtain a Vt/kg of 6 to 8 ml/kg with an active inspiration. Were studied the peak airway pressure (Paw) and breathing pattern. Were registered the Edi minimum and Edi maximum for determining PEEP and peak pressure, respectively, Vt, respiratory rate, FiO2 and blood gases serially. Results We observed synchrony between Edi signal and ventilator breaths in pressure control or Bivent, and when the patients have started spontaneous breaths (T signal) we move to pressure support. Low Edi minimum (0 to 1) was associated with overdistending the diaphragm and required decreasing the PEEP, contrary to high Edi minimum that was associated with higher tonic activity and dictated to raise the PEEP. During NAVA, the pressure delivered was proportional to the Edi. The NAVA level was continuously readjusted in proportion to the predicted inspiratory efort from the Edi signal. At the highest assist level, we found lower Vt/kg (6.1 ± 3 ml/kg vs 8.1 ± 1.8, P <0.001), and higher breathing frequency (19 ± 6.9 vs 11 ± 7, P <0.001) and peak EAdi (11.8 ± 8.5 vs 8.1 ± 7.7, P <0.002) in NAVA than in PSV. Conclusions The asynchrony during mechanical ventilation increases the cost of care, length of days on mechanical ventilation, and other morbidities associated with increased ICU stay. The Edi monitoring helps to understand other modes of ventilation and has been a great tool to decide the timing of a switch to NAVA and predict an early weaning. Systematically increasing the NAVA level reduces the respiratory drive, unloads respiratory muscles, and ofers a method to determine an assist level that results in sustained unloading, low Vt, and stable respiratory function when implemented for 3 hours. NAVA gives us the opportunity to augment these patients’ own drive to breathe enough to recover more quickly. References 1. 2. Brander L, et al.: Chest 2009, 135:695-703. Sinderby C, Beck J: Clin Chest Med 2008, 29:329-342. P206 Twenty-four-hour neurally adjusted ventilatory assist and volume cycled ventilation have similar efects on respiratory neuromuscular function in a porcine model of fecal peritonitis R Schroeder1, KA Ackermann1, D Tuchscherer1, S Djafarzadeh1, WJ Z`Graggen1, C Sinderby2, SM Jakob1, J Takala1, L Brander1 1 University Hospital of Bern, Switzerland; 2St Michael`s Hospital, University of Toronto, Canada Critical Care 2010, 14(Suppl 1):P206 (doi: 10.1186/cc8438) Introduction Sepsis and muscle inactivity may lead to neuromuscular dysfunction. Neurally adjusted ventilatory assist (NAVA) converts diaphragm electrical activity (EAdi) into airway pressure (Paw) and preserves respiratory muscle activity [1]. We hypothesised that respiratory neuromuscular function would be better preserved with NAVA compared with volume cycled ventilation (VCV) in early sepsis. S72 Methods Twenty-eight pigs (40.0 (37.6; 41.8) kg; median (quartiles)) were randomized (n = 7 per group) to fecal peritonitis or nonseptic controls ventilated for 24 hours with either NAVA or VCV (nonparalyzed, Vt 6 to 8 ml/kg, rate adjusted to suppress EAdi). Fluids and norepinephrine (NE) were used based on protocols to keep mean arterial pressure (MAP) >50 mmHg. Before sepsis and after 24 hours, transcutaneous supramaximal stimulations of the cervical phrenic nerve (tPNS) and expiratory occlusion manoeuvres (eOM) were performed. Latency and amplitude of diaphragm compound muscle activity potentials (CMAP) were measured during tPNS; maximal delections of Paw (ΔPaw), esophageal (ΔPes), and transdiaphragm (ΔPdi) pressures were measured during repetitive tPNS (40 Hz, 100 stimuli) and eOM. Results Hemodynamic parameters were not diferent among groups before sepsis and remained stable in controls. MAP did not change in septic NAVA but decreased in septic VCV animals from 91 (74; 95) mmHg before sepsis to 58 (57; 68) mmHg at 24 hours (P <0.001, MANOVA t-g interaction). The heart rate increased (P <0.001) and stroke volume decreased (P = 0.034) in both septic groups. Fluid balance was not diferent among septic groups. Three septic NAVA and six septic VCV animals received NE. CMAP latency and amplitude, as well as ΔPaw, ΔPes, and ΔPdi were not diferent among all groups during repetitive tPNS and eOM before sepsis and after 24 hours (P = NS). Conclusions Respiratory neuromuscular function is not afected by the mode of ventilation during the irst 24 hours of abdominal sepsis. Early efects of sepsis on neuromuscular function are not relected in respiratory muscle strength. NAVA may reduce the need for hemodynamic support in early sepsis. Acknowledgements Supported by SNF 3200B0-113478; Stiftung Anästhesiologie und Intensivmedizin, Bern. Reference 1. Brander et al.: Chest 2009, 135:695-703. P207 Efects of conventional and closed-loop neurally adjusted ventilatory assist in intubated spinal cord injured patients J Spahija1, M De Marchie2, K Trulandier1, A Moga3, P Bellemare1, S Delisle1, M Albert1 1 Hôpital du Sacré-Coeur de Montréal, Canada; 2Jewish General Hospital, Montreal, Canada; 3McGill University, Montreal, Canada Critical Care 2010, 14(Suppl 1):P207 (doi: 10.1186/cc8439) Introduction This study aimed to evaluate the efect of high versus low tidal volumes (VT) during volume control (VC) ventilation and neurally adjusted ventilatory assist (NAVA) in spinal cord injured (SCI) patients. We hypothesized that VC with higher VT would signiicantly unload and deactivate the diaphragm, whereas NAVA would not. Methods Seven intubated C3 to C7 SCI patients (age: 28 ± 12 years) were studied. Using VC (Servo300), VT was increased progressively (not exceeding 40 cmH2O or 2 l VT) (high volume) and then lowered until 6 ml/kg or intolerance (low volume). NAVA was then progressively adjusted targeting similar peak pressures. Finally subjects received 15 minutes each of: high VC, low VC, high NAVA, and low NAVA in randomized order. Results Despite comparable increases in peak airway pressure (Pmo), VT increased with VC but was unaltered with NAVA. Inspiratory and total breath durations were lower and respiratory rate higher with NAVA compared with VC during both assist levels. VC resulted in signiicant diaphragm unloading and deactivation whereas both were maintained during high and low NAVA. Complete diaphragm deactivation in more than 80% of breaths was observed during VC in ive of the patients. Table 1 (abstract P207) Low volume VT (l) 0.6 ± 0.2 Peak Pmo (cmH2O) 19.2 ± 3.2 High volume Low NAVA High P VC P NAVA vs NAVA level 1.3 ± 0.2 0.6 ± 0.2 0.6 ± 0.2 <0.001 <0.001 34.9 ± 2.6 18.4 ± 5.9 31.5 ± 5.9 NS <0.001 Mean EAdi (%) 3.3 ± 4.3 0.8 ± 1.7 6.8 ± 4.2 4.6 ± 3.0 0.004 0.03 Mean Pdi (cmH2O) 2.5 ± 3.1 -1.3 ± 2.1 4.3 ± 3.4 2.6 ± 2.6 0.02 0.009 VT, tidal volume; EAdi, diaphragm activation; Pdi, transdiaphragmatic pressure. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S73 Conclusions VC ventilation results in signiicant diaphragm unloading and deactivation especially at high assist levels, whereas diaphragm activation (EAdi) is maintained with NAVA. P208 A level of neurally adjusted ventilatory assist corresponds to low levels of continuous positive airway pressure and pressure support ventilation in patients preparing to be extubated from mechanical ventilation Y Klai-on, A Navasakulpong, A Wattanathum Phramongkutklao Hospital, Bangkok, Thailand Critical Care 2010, 14(Suppl 1):P208 (doi: 10.1186/cc8440) Introduction Neurally adjusted ventilator assist (NAVA) is a new mode of mechanical ventilation which delivers ventilator assist in proportion to electrical activity of the diaphragm (EAdi), as assessed by trans-esophageal electromyography, and an adjustable supporting level called the NAVA level. NAVA can be used as a supporting and weaning mode of ventilation [1-3]. However, a level of NAVA corresponding to continuous positive airway pressure (CPAP) and pressure support ventilation (PSV) in patients ready for extubation has not been established. Methods We carried out a prospective study in the medical ICU at Phramongkutklao Hospital involving patients who were considered by their physicians to be ready for extubation. Patients initially received PSV of 5 cmH2O, PEEP of 5 cmH2O, and FiO2 of 40% for 15 minutes (PS). Subsequently, each patient received a trial of NAVA mode with PEEP of 5 cmH2O, and FiO2 of 40% for 15 minutes (NAVA), and, inally, a 30-minute spontaneously breathing trial without ventilatory support (SBT). During these trials, the minute volume (MV), respiratory rate, EAdi, and airway pressure were measured. We determined the corresponding NAVA level with the level of PSV of 5 cmH2O and PEEP of 5 cmH2O using the NAVA level matching MV (±10%) received from the PSV. Results The NAVA level corresponding to the PSV of 5 cmH2O and PEEP of 5 cmH2O was 0.52 cmH2O/μV (0.2 to 1.2). The airway pressure during NAVA was 5.97 cmH2O (3.2 to 8) above PEEP level. The peak EAdi was not signiicantly diferent between the PS, NAVA, and SBT (11.58, 12.06 vs 12.65 μV; P = 0.6). Also, there was no signiicant diference in MV during the PS, NAVA, and SBT. Conclusions NAVA mode can be used as a weaning mode by decreasing the NAVA level. The reduced level of NAVA to 0.5 cmH2O/μV did not load respiratory muscle more than a low level of PSV and SBT. Thus, a NAVA level of 0.5 cmH2O/μV might be the level that is safe to discontinue ventilator support in patients without problems for resuming spontaneous breathing. References 1. 2. 3. Navalesi P, et al.: Curr Opin Crit Care 2003, 9:51-58. Sinderby C, et al.: Chest 2007, 131:711-717. Beck J, et al.: Pediatr Res 2007, 61:289-294. P209 Towards partially automated ventilation: adapting decision-making according to medical preferences S Lozano-Zahonero1, D Gottlieb2, J Guttmann2, K Möller1 1 Furtwangen University, VS-Schwenningen, Germany; 2University Hospital Freiburg, Germany Critical Care 2010, 14(Suppl 1):P209 (doi: 10.1186/cc8441) Introduction A novel methodology is proposed to adapt decisionmaking strategies into our fuzzy-based expert system, AUTOPILOT-BT [1]. The special features of this approach are: knowledge from clinical experts can be extracted in a setup simulating daily ICU routine; an automated process serves to obtain the required information and to create new fuzzy sets; and the fuzzy controller from AUTOPILOT-BT employs the newly derived fuzzy rules. Thus, the knowledge base can easily be modiied and the resulting mechanical ventilation therapies may be adapted to individual preferences of the clinician. Methods The methodology consists of: (i) Acquisition of decision-making strategies from single or groups of anesthesiologists. This can either be done with a questionnaire or with a PC-based program simulating the doctors every day situation in diagnosis. (ii) Deinition of fuzzy membership Figure 1 (abstract P209). Normal ventilation for healthy vs ARDS patients – fuzzy sets for paCO2 given from two clinicians: (left) C10, (right) C51. functions based on the acquired knowledge (fuzziication of the input). (iii) Construction of fuzzy inference rules and defuzziication or calculation of change in ventilator settings (controller action). This approach allows implementing clinician-dependent decision-making that relects individual preferences. Thus guidelines from EBM can be used but as well ICU speciics can be realized, for example diferent levels of acceptable hypercapnia in patients with acute respiratory distress syndrome (ARDS). Results Exemplarily Figure 1 shows, for healthy and ARDS lungs, the diference between two fuzzy sets for our paCO2 controller given from two clinicians (C10 and C51) with diferent expertise in mechanical ventilation. With the newly designed fuzzy sets, our AUTOPILOT-BT reacts according to the clinicians’ preferences, but still minimizes the time in which the patient is not ventilated within the speciied limits. Conclusions The system automatically implements the know-how of medical experts in ventilation management if the clinicians are willing to interact with the query system. The resulting strategy is mainly inluenced by the expertise, experience and demands of the clinician. Thus the AUTOPILOT-BT, has the potential to select established guidelines or to adapt the system to modiied ventilation therapies. Further clinical trials will test the actual clinical eiciency of diferent controllers. References 1. Lozano S, et al.: Tech Health Care 2008, 16:1-11. P210 Postoperative pulmonary complications in adult elective surgery patients in the US: severity, outcomes and resources use WL Linde-Zwirble1, JD Bloom2, RS Mecca3, DM Hansell4 1 ZD Associates LLC, Perksaie, PA, USA; 2Covidien, Boulder, CO, USA; 3University of California at Irvine, Orange, CA, USA; 4Massachusetts General Hospital, Boston, MA, USA Critical Care 2010, 14(Suppl 1):P210 (doi: 10.1186/cc8442) Introduction Postoperative pulmonary complications (PPCs) are associated with adverse outcomes and added resource use. However, PPCs vary in severity, and so may have very diferent outcomes. Methods We selected adult elective surgical cases from the Premier database for 2008. The PPC conditions identiied were: pneumonia; respiratory failure; bronchospasm; tracheobronchitis; pleural efusion; pulmonary collapse; ARDS; and pneumothorax. We stratiied PPC cases into levels: those with bronchospasm and no other PPC (BS), those with respiratory failure (RF) and all remaining (NRF). We examined incidence, length of stay, hospital mortality, and total cost. US national projections were made using Premier supplied projection weights. We calculated incremental resource use and outcomes by comparing cases with and without PPCs for each surgical condition and summarizing across all conditions. Results There were 738,039 cases in our cohort. At least one PPC was identiied in 85,435. BS occurred on 6.4% of cases (45,005), NRF in 3.8% (27,796) and RF in 1.7% of cases (12,634). BS was not associated with an increase in the risk of death (one added death per 5611 cases), but had signiicant increases in resource use: one added ICU admission per 14 cases; one added ICU day per ive cases; and one added hospital day and $1,563 added cost per case. NRF was associated with a modest increase in risk of death (one added death per 157 NRF cases) and substantial increases in resource use: one added ICU admission for every six cases; 0.66 ICU days per case; and three hospital days and $5,771 added cost per NRF case. RF was associated with greatly increased risk of death (one added death per Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 10 cases) and larger increases in resource use: one added ICU admission per two cases; 5 ICU days, 8 hospital days and $24,000 in added cost per RF case. Projecting to the US population there were 583,300 PPC cases, associated with 9,500 added deaths, 92,200 added ICU admissions, 584,200 added ICU days, 867,400 added loor days and $3.42 billion US in added costs. PPC add $717 to the average cost of elective surgery in the US. Conclusions PPCs are very common, occurring in one in eight elective postoperative patients. While BS was not associated with added deaths, all three PPC strata were associated with substantial increase in resource use. Better strategies for the prevention and management of PPCs could lead to greatly improved outcomes and substantial savings. P211 Increased duration of mechanical ventilation is associated with decreased diaphragmatic force G Hermans, A Agten, D Testelmans, M Decramer, G Gayan-Ramirez UZ Leuven, Belgium Critical Care 2010, 14(Suppl 1):P211 (doi: 10.1186/cc8443) Introduction Respiratory muscle weakness is an important risk factor for prolonged mechanical ventilation, and may be part of critical illness related polyneuropathy and myopathy. Animal data also strongly point to atrophy and weakness of the diaphragm due to mechanical ventilation itself, called ventilator-induced diaphragmatic dysfunction. Recently, measuring transdiaphragmatic pressure following magnetic stimulation (TwPdi BAMPS) was introduced in the ICU to evaluate diaphragm function [1,2]. We aimed to evaluate reproducibility of twitch TwPdi BAMPS in critically ill, mechanically ventilated patients. We also aimed to describe the relationship between TwPdi and duration of mechanical ventilation. Methods Prospective observational study in a medical ICU of a university hospital. TwPdi BAMPS was measured in critically ill and mechanically ventilated patients. Briely, the phrenic nerves were stimulated bilaterally from the anterior approach, at the posterior border of the sternocleidomastoid muscle, at the level of the cricoids using two igureof-eight 45 mm magnetic coils (Magstim, Dyfed, Wales) and a bistim (Magstim, Dyfed, Wales). A custom-built occlusion valve was used to create isometric conditions during stimulation. Oesophageal and abdominal pressure changes were measured using balloon catheters (UK Medical, Sheield, UK) inserted through the nose after local anaesthesia. Results Nineteen measurements were made in a total of 10 patients at various intervals after starting mechanical ventilation. In seven patients, measurements were made on at least two occasions with a minimal interval of 24 hours. The between-occasion coeicient of variation of TwPdi was 9.7%, which is comparable with data from healthy volunteers. Increasing duration of mechanical ventilation was associated with a logarithmic decline in TwPdi (R = 0.69, P = 0.038). This association was also found when cumulative time on pressure control ventilation (R = 0.71, P = 0.03) and pressure support ventilation (P = 0.05, R = 0.66) were considered separately, as well as for cumulative dose of propofol (R = 0.66, P = 0.05) and piritramide (R = 0.79, P = 0.01). Conclusions Increased duration of mechanical ventilation is associated with a logarithmic decline in diaphragmatic force. These indings are compatible with the concept of ventilator-induced diaphragmatic dysfunction. The observed decline may also be due to the cumulative dose of sedatives/analgesics or other co-factors, such as sepsis. References 1. 2. S74 Methods The trial has covered 30 injured patients aged from 21 to 60 years with 25 to 78% skin burns and PO2/FiO2 <300. Patients were randomized into two groups. The irst group was n = 13, PO2/FiO2 <300, 24 to 72 h after burn. The second group was n = 17, PO2/FiO2 <300, 4 to 11 days after burn. Injured persons were subjected to evaluation of cardiac index (CI), intrathoracic blood volume index (ITBI), extravascular lung water index (ELWI0 and pulmonary vascular permeability index (PVPI) by single transpulmonary thermodilution (PiCCOplus; Pulsion Medical Systems, Germany), calculation of oxygen delivery (DO2), and colloidal osmotic pressure of plasma. Grade of pulmonary damage was evaluated by Murrey, severity of dispragia by SOFA. Correlation analysis was performed using Pearson and Spearman criteria (r; P). Diferences were signiicant at P <0.05. Results Hypoxaemia (PO2/FiO2 = 259 ± 19) in the injured of the irst group was developing at the background of reduction of CI = 3.2 ± 0.5; ITBI = 751 ± 114; DO2 = 596 ± 124 (r = –0.92; P = 0.02). ELWI level was normal (7.3 ± 0.8). In the second group, reduction of PO2/FiO2 has been developing at the background of burn sepsis (average SOFA point = 7.0 ± 1.9, Murrey = 1.6 ± 0.4) and was caused by increasing of ELWI up to 9.0 ± 1.4 (r = –0.66; P = 0.002) and correlated with PVPI (r = 0.57; P = 0.01). There was no statistically signiicant correlation ELWI with ITBI and colloidal osmotic pressure of plasma (r = 0.13, r = –0.42). Conclusions Gas exchange disorders in patients of the irst group were caused by lack of perfusion and misbalance between oxygen delivery and demand. Reduction of oxygenation index in patients from the second group was accompanied by ELWI at the background of alteration of intravascular penetration and sepsis. P213 Invasive mechanical ventilation in cancer patients: prior non-invasive ventilation is a poor prognostic factor A Meert, T Berghmans, N Nayer, M Paesmans, E Markiewicz, M Hardy, J Sculier Institut Jules Bordet, Bruxelles, Belgium Critical Care 2010, 14(Suppl 1):P213 (doi: 10.1186/cc8445) Introduction Prior non-invasive ventilation (NIV) is associated with an increased mortality in patients with haematological malignancies and acute respiratory failure treated by invasive mechanical ventilation (IMV). Methods We have assessed whether NIV failure is an independent prognostic factor for hospital discharge in a general cancer population treated by IMV. One hundred and six patients with solid tumours and 58 patients with haematological malignancies were eligible for this retrospective study; 41 were treated by NIV before IMV. Results The main indications for mechanical ventilation were sepsis/ shock (35%), acute respiratory failure (33%), cardiopulmonary resuscitation (16%) and neurologic disease (10%). Respectively, 35%, 28% and 24% of the patients were extubated, discharged from the ICU and from the hospital. For patients treated with NIV prior to IMV, the rates were 22%, 17% and 10%, respectively. In multivariate analysis, three variables were independently associated with a decreased probability of being discharged from the hospital: NIV use before IMV (OR = 0.30, 95% CI: 0.09 to 0.95; P = 0.04); leucopenia (OR = 0.21, 95% CI: 0.06 to 0.77; P = 0.02) and serum bilirubin >1.1 mg/dl (OR = 0.38, 95% CI: 0.16 to 0.94; P = 0.04). Conclusions NIV failure before IMV is an independent poor prognostic factor in cancer patients treated by IMV. Watson AC, et al.: Crit Care Med 2001, 29:1325-1331. Laghi F, et al.: Am J Respir Crit Care Med 2003, 167:120-127. P212 Haemodynamics and volhaemic stage in patients with respiratory disorders to thermal injury K Shatovkin, I Shlyk Djanelidze Research Institute of Emergency Medicine, Saint-Petersburg, Russia Federation Critical Care 2010, 14(Suppl 1):P212 (doi: 10.1186/cc8444) Introduction The aim of the investigation was to study the parameters of haemodynamics, gas exchange and volhaemic status in patients with severe thermal injury. P214 Laryngeal angioedema: do we need a new treatment algorithm in the ER? K Stelter1, A Leunig1, M Jacob1, M Bas2 1 Ludwig Maximilians University, Munich, Germany; 2Technical University, Munich, Germany Critical Care 2010, 14(Suppl 1):P214 (doi: 10.1186/cc8446) Introduction Laryngeal angioedema (AE) could be life-threatening and is frequently due to allergic reactions. Other causes, that is bradykininmediated conditions, have to be taken into account. The aim of our survey is to provide information on the incidence, diagnosis and potentially new treatment options for laryngeal AE. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S75 before and 1 minute after insertion. Postoperative complications were noted. Results The success rate of insertion at the irst attempt was higher for the rotational technique (95.7% vs 76.1%, P <0.001). The overall success rate – that is, successful insertion within three attempts – was 100% for the both techniques. Systolic, diastolic and mean blood pressure and heart rate increased signiicantly with the standard technique (P <0.001). Systolic blood pressure and heart rate increased signiicantly with the rotational technique (P <0.01). The incidence of blood staining (8.7% vs 23.9%, P = 0.048) was lower with the rotational technique. Conclusions The rotational technique is more successful than the standard technique and is associated with less pharyngeal mucosal trauma, as evidenced by a lower incidence of mucosal bleeding. Reference 1. Figure 1 (abstract P214). Efect of 30 mg icatibant s.c. on a laryngeal edema due to ACEI. Methods The data for 102 patients who were treated for swelling of the larynx at the Department of Otorhinolaryngology of Ludwig-MaximiliansUniversity of Munich from 2004 to 2008 were evaluated in a retrospective survey. Results Causes of laryngeal AE were in 26 patients an allergic reaction, in 33 cases were due to radiotherapy after cancer, 32 patients took an angiotensin-converting enzyme inhibitor (ACEI), one patient had a hereditary angioedema (HAE) and in 10 patients are unknown. All patients independent from the underlying cause were treated with high-dose intravenous steroids, 69 patients with antihistamines, 33 with epinephrine (inhalation or i.m.), two patients with ACEI-induced AE were successfully treated with icatibant. Ten patients needed an intubation, 11 a tracheotomy, one patient an emergency coniotomy to preserve the airway. All 11 tracheotomy patients sufered from cancer. Nine out of 10 intubated patients took an ACEI and were extubated on the ICU after 2 to 7 days. Conclusions According to our experience 80% of the patients with laryngeal swelling and upper airway obstruction react well to the standard therapy with steroids, epinephrine and antihistamines, indicating that the AE is histamine induced. In contrast these drugs have almost no efect on bradykinin-induced angioedema; that is, AE induced by ACEI. There is preliminary evidence that the bradykinin B2 receptor antagonist icatibant that is approved for treatment of HAE type I and II may also be efective in ACEI-induced edema. P215 Comparison of two insertion techniques of the ProSeal laryngeal mask airway: standard versus 90° rotation in pediatric patients M Yun1, J Hwang1, A Oh1, M Han1, H Kim2, H Na1, S Lee2 1 Seoul National University Bundang Hospital, Seongnam, Republic of Korea; 2 Seoul National University Hospital, Seoul, Republic of Korea Critical Care 2010, 14(Suppl 1):P215 (doi: 10.1186/cc8447) Introduction This study compared two insertion techniques of the ProSeal laryngeal mask airway in pediatric patients. Methods A total of 92 pediatric patients (American Society of Anesthesiologists physical status I or II; age 3 to 12 years) undergoing ophthalmologic surgery were randomly allocated to the standard or rotational technique groups. In the standard technique group (n = 46), ProSeal laryngeal mask airway insertion was performed by a single experienced user using digital manipulation. In the rotational technique group (n = 46), the ProSeal laryngeal mask airway was rotated counterclockwise through 90° in the mouth and advanced until the resistance of the hypopharynx was felt, and then straightened out in the hypopharynx (n = 80). The ease of insertion was assessed by the success rate at the irst attempt. Heart rate and mean blood pressure were recorded 1 minute Hwang JW, Park HP, Lim YJ, Do SH, Lee SC, Jeon YT: Comparison of two insertion techniques of ProSeal laryngeal mask airway: standard versus 90-degree rotation. Anesthesiology 2009, 110:905-907. P216 Endotracheal intubation in the critically ill: complication rate and use of intubation aids A Verstraete, K Colpaert, J Nollet, J Decruyenaere Ghent University Hospital, Ghent, Belgium Critical Care 2010, 14(Suppl 1):P216 (doi: 10.1186/cc8448) Introduction Intubation in the ICU is associated with a high complication rate. No data exist about how frequently intubation aids are used in the ICU. In our ICU we have the availability of diferent intubation aids, and perform an annual training course on diicult intubation strategy. We wanted to evaluate the incidence of diicult intubation, together with the complication rate and the use of intubation aids in our ICU. Methods We performed a prospective cohort study in a 56-bed academic tertiary care hospital of all patients requiring intubation during their ICU stay during a 5-month observation period in 2008. Standardized data forms were used to collect detailed information on the intubating physicians, supervisors, techniques, medications and complications. Results We enrolled 120 patients requiring immediate intubation in 37.5%, semi-urgent (<30 minutes) intubation in 50.8%, and semi-elective intubation in 11.7%. All intubations were successful. Diicult intubation was anticipated in 17.5% of all cases, although only 28% of these efectively proved to be diicult. Immediate intubation was possible in 74.2% of all cases, and diicult intubation (at least three attempts) occurred in 6.6%. Furthermore, 4.2% of intubations required 10 minutes or more. Nonexperts experienced more complications, and performed successful intubation in only 37.7%. One-third of all intubations were supervised by an intensive care physician, although this was not associated with a decrease of complication rate (65% vs 57.5%). Techniques most commonly used for diicult intubation management were change in intubator (48.4%), change in patient position (29%), BURP maneuver (19.3%) and use of a Gum elastic bougie (19.3%). Overall risk of complications occurring was 76.6%. Hypoxia was most common (40%), followed by hypotension (31.6%), heart rhythm disorders (4.1%) and oesophageal intubation (3.3%). Neuromuscular blockade was used in all but one patient. Hypnomidate was used in 31.6% of intubations, preferentially in patients with shock. The rate of complications or mortality did not signiicantly difer according to the hypnotic drug used. Conclusions Intubation in the ICU is frequently associated with complications, most commonly hypoxia and hypotension. The use of the Gum elastic bougie is required in 19.3% of cases, and results in achieving a 100% successful intubation rate. P217 Intensity and adequacy of laryngoscope light in seven intensive care units J Hodd, S Gupta, N Rahman, P Young Cleveland Clinic, Cleveland, OH, USA Critical Care 2010, 14(Suppl 1):P217 (doi: 10.1186/cc8449) Introduction The objective of the study was to determine the adequacy of illumination of laryngoscopes in seven critical care units (CCU) (two Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S76 diference was noted between the two groups in hemodynamic setting, saturation, Ramsey score and airway-trauma-related side efects. Conclusions Our experience demonstrated that the Airtraq could be used during awake sedations and may be a promising alternative device for diicult airway management as a valid alternative to the traditional iberoptic bronchoscope. References 1. 2. Maharaj CH, Costello JF, Harte BH, Lafey JG: Evaluation of the Airtraq and Macintosh laryngoscopes in patients at increased risk for diicult tracheal intubation. Anaesthesia 2008, 63:182-188. SIAARTI Study Group: Recommendations for airway control and diicult airway management. Minerva Anestesiol 2005, 71:217. Figure 1 (abstract P217). Laryngoscope illumination. medical, three surgical, two neurosurgical). Laryngoscopes in the Cleveland Clinic are routinely checked twice daily by healthcare workers. Conirmation of the presence of bulb illumination in ambient room light, however, may not be a suicient test. In the CCU environment successful tracheal intubation may be time sensitive, and failure of adequate illumination of the larynx impedes visualization. Adequacy of lighting is subjective; however, the Health and Safety Executive suggests 500 Lux as a minimum for work requiring the perception of ine detail [1]. Methods In a single-day spot audit, all clinically available laryngoscopes were evaluated for brightness. Battery voltage was measured with a voltmeter (Innova 3320; Fountain Valley, CA, USA), then the batteries were replaced for new prior to re-measuring of illumination. The bulb was then replaced for new and the illumination measured again. Illumination measurements were taken from tip of the blade at 90° using a luxometer (Model CA813; AEMC instruments, Foxborough, MA, USA) in a lightproof box. Results Forty-six laryngoscopes were tested. All had traditional vacuum incandescent bulbs. Twelve (26%) fell below 1,000 Lux and six (13%) fell below the 500 Lux minimum. The failures were corrected by battery replacement in 25% and by bulb replacement in the remaining 75% (see Figure 1). Conclusions Simply checking laryngoscopes for the presence of illumination on a regular basis is insuicient to ensure best or even adequate function. Poor function is as frequently related to bulb dysfunction as battery fatigue. Institutions should consider quality control and maintenance programs or consider more advanced laryngoscopic lighting (for example, LED or halogen bulbs). References 1. Goodwin et al.: Anaesthesia 2006, 61:792-799. P218 Airtraq: new device in patients at increased risk for diicult tracheal intubation S Tomasino, E Tricarico, C Gonano, E Zompicchiatti, L D’Orlando ASS n3 Alto Friuli, Tolmezzo, Udine, Italy Critical Care 2010, 14(Suppl 1):P218 (doi: 10.1186/cc8450) Introduction A novel single-use indirect laryngoscope, the Airtraq (A), has been demonstrated to be of promise in the normal and simulated diicult airway [1]. We compared the ease of awake intubation using the A against the iberoptic bronchoscope (F) in patients at increased risk for diicult tracheal intubation [2]. Methods In this randomised, controlled, clinical trial we enrolled patients at increased risk for diicult tracheal intubation, undergoing surgical operations requiring tracheal intubation. With ethics committee approval and written, informed consent, patients were randomly assigned to Fibroscope-guided tracheal intubation (F group) or Airtraq-guided intubation (A group). All patients, maintained in spontaneous breathing all through the procedure, received awake intubation performed by one of three anesthetists expert in diicult airway management. All patients received a topical airway anesthesia with 2% lidocaine and total intravenous anesthesia (TIVA) performed with propofol c.i. with an efecter site concentration of 1.5 μg/ml. Results We enrolled 30 patients, 15 in the F group and 15 in the A group. All patients were successfully intubated in both groups. In group A we assessed a short time and a small amount of attempts of intubation with a statistically signiicant diference between the two groups (P <0.05). No P219 Evaluation of a new tracheostomy technique for morbidly obese patients on an intensive care unit A Mallick1, A Bodenham1, C Waldmann2, M Verch3, F Brettner4, J Diebolt5, M Meier6 1 Leeds General Inirmary, Leeds, UK; 2The Royal Berkshire Hospital, Reading, UK; 3Herzchirurgie Heidelberg, Germany; 4KH Barmherzige Bruder, Munich, Germany; 5Hôpital Haute Pierre, Strasbourg, France; 6University of Alberta Hospital, Edmonton, Canada Critical Care 2010, 14(Suppl 1):P219 (doi: 10.1186/cc8451) Introduction Tracheostomy in morbidly obese patients is generally performed by surgical technique. Although PDT has a low complication rate in nonobese patients, it is not technically possible to use standard PDT kits in morbidly obese patients with thick necks. The skin to trachea distance renders traditional-length tracheostomy tubes or dilators too short. Recently a tracheostomy kit (Uniperc, Smith Medicals, UK), designed for obese patients has become available. This kit consists of an S-shaped dilator and a long adjustable reinforced tracheostomy tube. The objective of this study was to evaluate the safety and complications of this new technique in morbidly obese patients. Methods The study was approved and patients’ relatives were informed of the use of the new device. A total of 32 (male:female 21:11) morbidly obese (BMI mean 36 ± 4.3) patients (aged 27 to 57 years) were enrolled. Patients were anaesthetised and ventilated with 100% oxygen. PDT was carried out under endoscopic control with stomal dilation using the single stage S-shaped dilator and a reinforced adjustable lange tracheostomy tube size 7 to 9 mm ID as required. Measurements were taken including the distance from skin to the trachea using the graduated introducer needle and the initial small dilator, neck circumference, and length of the tracheostomy tube at the skin. Complications including accidental extubation, paratracheal placement, pneumothorax, major or minor bleeding, hypoxia, transient hypotension, subcutaneous emphysema or death were recorded. Patients were followed up with the inner cannula changed every day. Results Thirty-two patients underwent PDT using this new kit. Patients were ventilated for a mean of 10 days (range 3 to 37) prior to tracheostomy. The mean neck circumference was 46.3 mm (37 to 55). The depth of the trachea from skin was a mean of 39 mm (15 to 80). The operators had no problem in stomal dilation using the single-stage dilator. The length of the tracheostomy tube adjusted at the skin ranged from 8 to 20 cm with a mean of 12 cm. No major complications were observed except two minor bleeding episodes and transient desaturation in one patient. The tracheostomy tube was decannulated after a mean of 25 days (6 to 82). Conclusions Bedside PDT can be performed in morbidly obese ICU patients using this new single-stage dilator and the adjustable lange reinforced tracheostomy tube with a low rate of complications. Further studies with longer-term follow-up are required. P220 Our percutaneous tracheostomy experiences using the rotationdilatation screw method C Kaymak, N Ozcan, H Basar, A Ozcan Ankara Training and Research Hospital, Ankara, Turkey Critical Care 2010, 14(Suppl 1):P220 (doi: 10.1186/cc8452) Introduction A tracheostomy procedure is indicated for urgent airway control, to avoid complications of lengthened endotracheal intubation Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 and to make weaning easier. Today, percutaneous tracheostomy techniques are preferred to classical surgical tracheostomy and the use is spreading. Ciaglia’s multiple dilatation technique, the Blue Rhino single dilatation technique, the Griggs dilatation forceps technique and the rotation-dilatation screw technique are the most preferred techniques for percutaneous tracheostomy [1,2]. The aim of this study is to retrospectively assess the techniques used for tracheostomy, tracheostomy time after intensive care admittance, length of intensive care stay and tracheostomy complications in our clinic. Methods After approval of the hospital ethics committee, iles of the patients on whom the tracheostomy was performed between 2007 and 2009 were evaluated retrospectively. Demographic data of the patients, tracheostomy time after intensive care admittance, length of total intensive care stay and related complications were registered. Results Files of 35 patients were evaluated on whom tracheostomy was performed between 2007 and 2009. The male-to-female ratio was 17/18, mean age of the patients was 57.4 ± 20.1 years (16 to 81 years, min to max), mean intensive care stay was 33.4 ± 26.4 days (5 to 103 days, min to max). Mean tracheostomy time after intensive care admittance was 13 ± 8 days (2 to 45 days, min to max). The rotation-dilatation screw technique was used for 34 patients and the Griggs dilatation forceps technique was preferred for one of the patients. No complication was observed for any of the patients. Conclusions Studies comparing the ease of performance, early and late complications and long-term results of diferent percutaneous tracheostomy techniques do not exist. Diferent advantage/disadvantage ratios are reported in literature related to early and late tracheostomy performance time after admittance. In our clinic practice, the decision for the tracheostomy time is diferent for each patient. The mean tracheostomy time shows our clinic prefers late tracheostomy. In the aspect of complications, we did not observe complications reported in the literature. References 1. 2. Ciaglia P, et al.: Chest 1985, 87:715-719. Sengupta N, et al.: Anesth Analg 2004, 99:188-192. S77 P222 Recruitment maneuver for prevention of alevolar derecruitment during percutaneous dilation tracheostomy F Franchi, AI Di Chiaro, M Fiorillo, S Scolletta, P Mongelli, G Coratti, L Cubattoli University of Siena, Italy Critical Care 2010, 14(Suppl 1):P222 (doi: 10.1186/cc8454) Introduction Alveolar derecruitment is an early complication of percutaneous dilational tracheostomy (PDT). The aim of this prospective study was to evaluate the eicacy of performing a recruitment maneuver (RM) before tracheostomy, in order to prevent the alveolar derecruitment in critically ill patients. Methods We enrolled 16 patients admitted to the ICU between December 2008 and July 2009, with PaO2/FiO2 ratio ≤3 who underwent PDT. We used the Ciaglia/Blue Rhino technique with endoscopic guidance throughout the procedure. Patients were ventilated before and during PDT on volumecontrolled mechanical ventilation (tidal volume of 6 ml/kg body weight) and FiO2 set at 1. Patients were randomized into two groups: MRa group (seven patients who underwent RM 10 minutes before PDT) and no-MRa group (nine patients without application of RM before PDT). RM was performed by imposition of continuous positive airway pressure (CPAP) of 40 cmH2O for 40 seconds. We collected gas exchange, respiratory and hemodynamic data at four times: 1 hour before RM (T1), 5 minutes after RM (T2), 5 and 30 minutes after PDT (T3 and T4, respectively). Results The average duration of the technique was similar in both groups: 20 ± 3.5 minutes (MRa) vs 17.5 ± 3.2 minutes (no-MRa). MR induced a statistically signiicant increase (P <0.05) in PaO2/FiO2 ratio of MRa patients at T2, T3, T4 (Table 1). We did not ind signiicant diferences of respiratory and hemodynamic data between groups; MR did not induce cardiovascular instability: the mean cardiac output was 5.2 ± 2.2 vs 4.9 ± 1.5 l/min (MRa vs no-MRa, respectively). Table 1 (abstract P222). PaO2/FiO2 in MRa and in no-MRa groups P221 Single-step vs balloon dilatation tracheostomy: a pilot study on 20 tracheostomies L Perretta1, S Biondi2, I Guerri2, N Maccarone2, L Tutino1, A Nella1, M Linden1, R Cammelli1, G Cianchi1, M Bonizzoli1, R Spina1, G Zagli1, A Peris1 1 Careggi Teaching Hospital, Florence, Italy; 2Postgraduate School of Anesthesia and Intensive Care, University of Florence, Italy Critical Care 2010, 14(Suppl 1):P221 (doi: 10.1186/cc8453) Introduction The Ciaglia Blue Rhino percutaneous dilatational tracheostomy (PDT) technique, introduced in 1998 as a modiication of the original procedure described in 1985, has been indicated as procedure of choice (level 2C) because of its technical simplicity and short procedure time. Recently, a modiied balloon dilatation technique (Ciaglia Blue Dolphin) has been introduced with the intention to increase feasibility and safety. Here we report our initial experience in Ciaglia Blue Dolphin tracheostomy in comparison with a prospective control group of Ciaglia Blue Rhino procedures, which are actually the goal-standard in our ICU. Methods Twenty consecutively admitted patients in the Emergency Department ICU (Careggi Teaching Hospital, Florence, Italy) requiring percutaneous dilatational tracheostomy (PDT) were treated with Ciaglia Blue Dolphin (irst 10, group D) and Ciaglia Blue Rhino (second 10, group R). Demographic, clinical and procedural data were collected. PDTs were all performed with bronchoscopic video guidance. The Mann–Whitney test was used to compare continuous variables. Results Patients of the two groups were similar for mean age (51.2 and 53.4 years old, respectively), body mass index (25.1 vs 24.8, respectively) and severity of illness (SAPS II: 44.3 vs 45.4, respectively). Group D showed a signiicant higher procedural duration (measured from tracheal puncture to tracheostomy tube positioning) than group R (4.3 minutes vs 2.6 minutes; P <0.01). Conclusions Despite recent reports in literature, we did not found substantial advantage in the use of Ciaglia Blue Dolphin with respect to the wider accepted Ciaglia Blue Rhino. Moreover, the higher cost of the new kit should be taken into consideration. In our opinion, complications such as tracheal posterior wall injury, pneumothorax, and pneumomediastinum can be avoided using the bronchoscopic video guidance. T1 T2 T3 T4 MRa PaO2/FiO2 182.8 ± 121.5 464.1 ± 119.7* 360 ± 138.8* 360.4 ± 79.7* no-MRa 247.1 ± 121.9 228.1 ± 116.3 126.5 ± 76.9 163.5 ± 84.5 *P <0.05. Conclusions RM with CPAP performed before PDT could be performed safely to prevent alveolar derecruitment due to PDT. P223 An audit of timing of tracheostomy formation in neurosurgical patients: how long should we wait? P Bearield, B Agarwal, S Ward, D Martin, S Shaw Royal Free Hospital, London, UK Critical Care 2010, 14(Suppl 1):P223 (doi: 10.1186/cc8455) Introduction In neurosurgical patients requiring ventilation on the ICU, a tracheostomy is frequently formed to facilitate airway protection and weaning from the mechanical ventilator. However, the issue of when to form a tracheostomy remains contentious. In order to better inform our decision-making processes we audited practice within our own institution. Methods A retrospective study was conducted in which the ICU charts of all neurosurgical patients admitted to a tertiary referral ICU during the calendar year 2007 were reviewed. Patients who did not require mechanical ventilatory support or who died within 7 days of admission were excluded. Demographic data, diagnosis, duration of mechanical ventilation, ICU day of stay on which tracheostomy was formed, and ICU length of stay were recorded and the data analysed accordingly. Results A total of 106 patients were included, 65 male and 41 female. The mean age was 49 years. Sixty-three patients were able to be separated from the mechanical ventilator within 7 days of commencement of ventilation via a cufed oral endotracheal tube. Of the remaining 43 patients, 34 (79%) went on to undergo tracheostomy formation as determined by the attending intensivist. In this group the median time of tracheostomy formation was 13 days. The median time from tracheostomy formation to separation from the mechanical ventilator was 3 days. Of those patients Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 who could not be extubated within 7 days of ventilatory support, nine (14%) were successfully separated from the mechanical ventilator without the need for a tracheostomy. There were no signiicant diferences in age or diagnosis between the two groups. Conclusions Our data suggest that the failure of a neurosurgical patient to separate from the mechanical ventilator within 7 days is predictive of the eventual requirement for tracheostomy formation. In light of this we intend to expand our sample size over a 5-year period and subject the data to multivariate regression. References 1. 2. [www.tracman.org.uk] Griiths J, Barber VS, Morgan L, Young JD: Systematic review and metaanalysis of studies of the timing of tracheostomy in adult patients undergoing artiicial ventilation. Br Med J 2005, 330:1243-1246. P224 Percutaneous dilational tracheotomy in adult burn patients P Zeyneloglu, A Pirat, C Aydogan, G Arslan, M Haberal Baskent University Faculty of Medicine, Ankara, Turkey Critical Care 2010, 14(Suppl 1):P224 (doi: 10.1186/cc8456) Introduction Few studies have focused on the safety and potential beneits of tracheotomy in burn patients. The purpose of this study is to determine the safety and eicacy of percutaneous dilational tracheotomy (PDT) in patients with burn injury. Methods A retrospective chart review was completed for patients admitted to Baskent University Burn Institute, from January 2003 through December 2008, who underwent tracheotomy during their hospitalization. Parameters recorded included demographics, extent of burn, timing of tracheotomy and presence of inhalation injury. Other variables measured were the arterial blood gas indings and lung compliance before and after PDT and PDT-related complications and mortality. Results Out of 325 patients, 17 patients (67% male) with a mean age of 33.1 ± 15.9 years and a mean total body surface area involvement of 51 ± 16% with a 40% of inhalation injury underwent PDT. Tracheotomies were performed within 48 hours after endotracheal intubations. All PDTs were performed at bedside by experienced staf anesthesiologists with direct bronchoscopic guidance. The site of intended tracheotomy was afected in 52% of patients. There were no procedural failures and no PDT-related complications and deaths. The calculated lung compliance and PaO2:FiO2 ratio improved after PDT (36.2 ± 12.9 vs 47.3 ± 16.5 ml/cmH2O and 243 ± 81 vs 350 ± 104, respectively). Conclusions The results suggest that PDT is an eicacious and safe technique for airway management in patients with burn injuries. Besides improved ventilatory mechanics, PDT may also beneit the patient with severe burns by earlier mobilization and ease of suctioning, oral intake and ability to communicate by mouthing words. P225 Safety of percutaneous tracheostomy in trauma patients IM Maldonado, SB Becker Maimonides Medical Center, Brooklyn, NY, USA Critical Care 2010, 14(Suppl 1):P225 (doi: 10.1186/cc8457) Introduction Percutaneous tracheostomy is a common procedure in many trauma ICUs. A concern about the safety of performing percutaneous tracheostomy in patients with no cervical spine clearance or cervical spine injury has limited its adoption for some surgeons. Most experts recommend the use of iberoptic bronchoscopy during the insertion of percutaneous tracheostomy. Methods: From January 2001 to December 2007 we retrospectively evaluated the medical records of all patients with blunt trauma who required tracheostomy in a level II trauma center. Data were gathered from a trauma registry database and medical records. Patients were divided in two groups, open tracheostomy (OT) and percutaneous tracheostomy (PT). Patient age, Injury Severity Score (ISS), type of tracheostomy insertion method, cervical spine clearance status prior to tracheostomy, presence of cervical spine injury, use of bronchoscopy assistance in percutaneous tracheostomy, and immediate complications post tracheostomy were recorded for each patient. S78 Results The total number of tracheotomies during the study period was 220, of which 125 (56%) were PT and 95(44%) were OT. Both groups were similar in age, sex and ISS distribution. Of the OT group, 60 (63%) were done in patients with no cervical spine clearance or cervical spine injury. There were no immediate complications reported in the OT group. The PT group had 63 cases (50.4%) done with no preoperative cervical spine clearance or positive for cervical spine injury. The PT group underwent the procedure without bronchoscopy assistance in 95% of the cases. Two cases (1.5%) in the PT group were reported with postoperative bleeding from the tracheostomy site that did not required intervention. Both cases were PT done without bronchoscopy assistance and did not have preoperative cervical spine clearance. No other immediate complications were reported. Conclusions The results of this study suggest that PT is safe in trauma patients without preoperative cervical spine clearance or with cervical injuries as compared with the OT group. Most of the PT cases were done without bronchoscopy assistance (95%). This inding suggests the need for further study to clarify the role of bronchoscopy assistance in PT. P226 Safety of balloon dilatational tracheostomy with the Ciaglia Blue Dolphin device A De Nicola, MJ Sucre San Leonardo Hospital, Castellamamre di Stabia, Italy Critical Care 2010, 14(Suppl 1):P226 (doi: 10.1186/cc8458) Introduction Percutaneous dilatational tracheostomy (PDT) has gained widespread acceptance in many ICU and trauma centers as a viable alternative approach. Numerous investigative reports show that all traditional techniques for PDT have similar complications. The most dangerous complication is posterior tracheal wall damage during insertion of the dilational device employing downward pressure. The Ciaglia Blue Dolphin (CBD) is an innovative device for PDT using radial balloon dilation. This technique has the potential advantage of less tracheal damage over other methods by avoiding downward pressure to enter the trachea [1,2]. Methods Case series of consecutive ICU patients with acute respiratory failure who required tracheostomy for failure to wean and continued mechanical ventilatory support. We report our clinical experience of 22 percutaneous tracheostomies performed using the CBD system (Cook, Bloomington, IN, USA). Informed consent was obtained from each patient, or family member. All procedures were performed under direct visualization using a ibreoptic bronchoscope on anaesthetised patients. The technique relies on the employ of a balloon-tipped catheter loaded over the guidewire. The balloon was inlated with saline up to 11 atmospheric pressure for 30 seconds to create a tracheostoma. A preloaded tracheostomy tube was then inserted through the stoma following balloon delation. Results Bedside PDT with the CBD system was successfully performed in the ICU for all 22 patients. Tracheostomies were performed within a mean time of 4.1 ± 1.4 minutes of the tracheal needle entry and with negligible blood loss in all patients. The procedure was not associated with a decrease in SpO2 at the time of balloon inlation. Procedural complications were limited to one patient requiring the repetition of balloon inlation for tracheostomy tube placement. There were no other immediate medical or technical problems. Conclusions The CBD has been shown to be a safe, quick and successful alternative to the traditional PDT (PercuTwist, guidewire dilating forceps, and so forth) that have a tendency to go too far and perforate the tracheal rings: the intensivist performing PDT should be aware when making the decision as to which approach to use. In our hospital, the CBD method has become the procedure of choice. References 1. 2. Byhahn C, et al.: Crit Care 2008, 12(Suppl 2):P333. Gromann TW, et al.: Anesth Analg 2009, 108:1862-1866. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P227 Inluence of the cuf pressure on the swallowing relex in tracheostomized ICU patients R Amathieu, D Luis, W Kamoun, V Slavov, G Dhonneur CHU APHP Jean Verdier, Bondy, France Critical Care 2010, 14(Suppl 1):P227 (doi: 10.1186/cc8459) Introduction Because recovery of an eicient swallowing relex is a determining factor for patient’s spontaneous rehabilitation of airway protective relexes, we have studied the inluence of cuf pressure of the tracheostomy tube on the swallowing relex elicited in tracheostomized ICU patients. Methods Twelve conscious eupneic adult patients were studied. Simultaneous electromyography of submental muscles [1] and acceleromyography of laryngeal elevation [2] were measured during relex swallows elicited by pharyngeal injection of distilled water. After cuf delation, instrumental characteristics of the swallowing relex (latency time, electromyography and acceleromyography peak and amplitude) were measured at 10, 15, 20, 25, 30, 40, 50, and 60 cmH2O of air-illed induced randomly imposed cuf pressure. Results Cuf pressure was inversely correlated to both electromyography and acceleromyography characteristics of the swallowing relex. Latency time of the swallowing relex and cuf pressure were linearly correlated. Instrumental characteristics of the swallowing relex deteriorated for a cuf pressure threshold >22 cmH2O (extremes 15 to 40). Conclusions We have demonstrated that instrumental characteristics of the swallowing relex were inluenced by cuf pressure in the tracheostomy tube. Increasing cuf pressure afected both the setting and the muscular activity of submental muscles during relex swallows. Our data suggest that peripheral mechanical constraints and centrally controlled inhibition may be involved in cuf pressure rise induced deterioration of the swallowing relex. Our report has several implications for intensive care daily clinical practice. In case of dysphagia, swallowing function should be evaluated and re-educated with a cuf pressure tidily controlled at 20 cmH2O. References 1. 2. Nishino T: J Appl Physiol 1991, 70:888-993. Reddy NP: J Rehabil Res Dev 2000, 37:361-372. P228 Microaspirations during mechanical ventilation: polyurethane versus polyvinyl cufed endotracheal tubes P Bulpa, S Bouhon, F Schryvers, J Jamart, P Evrard, I Michaux, A Dive, T Vander Borght, B Krug Mont-Godinne University Hospital, Yvoir, Belgium Critical Care 2010, 14(Suppl 1):P228 (doi: 10.1186/cc8460) Introduction Mechanically ventilated (MV) patients are prone to develop ventilator-associated pneumonia. One of the major risk factors is microaspirations of supraglottic secretions past the endotracheal tube cuf (usually in polyvinyl (PV)). A novel polyurethane (PUE) cuf was designed to minimize these leakages. We therefore compared the sealing capacities of the two tubes in MV patients. Methods Twenty-nine consecutive MV patients (mean age ± SD: 68 ± 13, 21 males), were randomly allocated to receive either a PV (HI-LO Evac, Mallinckrodt) or a PUE (SEALGUARD Evac, Mallinckrodt) cufed endotracheal tube (size: 9 for men; 8 or 8.5 for women, as a rule). We excluded patients with emergency intubation, unstable haemodynamics, severe respiratory failure or patients with history of tracheal/laryngeal disease. In each patient, cuf pressure was maintained at 30 cmH2O, and ventilator parameters were set to plateau pressure ≤30 cmH2O; patients were fasting and placed in a strict semirecumbent position (45°). Radioactivity of tracheal aspirates was assessed sequentially (hourly samplings from T0 to T6 hours, then T8 hours and T12 hours) after injection of 74 MBq 99mTc-DTPA diluted in 5 ml of 0.9% NaCl just above the cuf via the aspiration channel of the tube. Additionally, kinetics of respiratory tract contamination was followed by simultaneous pulmonary images using a scintillation camera. Data were blindly analysed by nuclear physicians. The study was approved by the hospital ethics committee and informed consent was obtained from relatives. Results Sixteen PUE and 13 PV cufed tubes were compared. The study was performed 3.2 ± 2.8 days after intubation and 8.3 ± 9.6 days after ICU S79 admission (mean ± SD). Ventilator parameters were the following: volume control or pressure support but one on T tube, FiO2 was 0.43 ± 0.14, PEEP 6 ± 2 cmH2O. Leakages were observed in 11/29 patients (38%), with similar rate of aspiration in PUE (5/16) and PV (6/13) groups (P = NS). Leakages were more frequently observed in female (7/8) than in male patients (4/21) (P <0.001). There was a trend to decreased frequency of aspiration in patients with larger tubes (size 9 vs 8.5: P = 0.062). Conclusions Both PUE and PV cufed endotracheal tubes are poorly efective in preventing microaspirations in MV patients. Tube size and/or gender may be more important than cuf composition in the prevention of aspiration during MV. P229 Do endotracheal tubes prevent microaspiration? P Lichtenthal1, U Borg2, D Maul3 1 University of Arizona, Tucson, AZ, USA; 2Covidien, Boulder, CO, USA; 3 Pre-Clinical Research Services, Fort Collins, CO, USA Critical Care 2010, 14(Suppl 1):P229 (doi: 10.1186/cc8461) Introduction For decades it was assumed that cufed endotracheal tubes prevented aspiration. However, currently used cufed tubes do not prevent the development of post-intubation pulmonary complications caused by microaspiration [1,2]. A new taper-shaped cufed tube (TaperGuard (TG)) has recently been introduced. The aim of this study was to compare this tube with a traditional tube (Hi-Lo (HL)) in an aspiration pig model. Methods Fourteen pigs between 65 and 75 kg were studied. The pigs were randomly intubated with either TaperGuard (tapered cuf ) or HiLo (barrel cuf ) tubes. The tube size was either 7.0 or 8.5 depending on weight. Cuf pressures were maintained between 24 and 27 cm water. After intubation, 0.3 ml/kg acidic blue dye (ph 2.5) was placed on top of the cuf. The animals were ventilated for 3 hours. The animals were then sacriiced and the tracheobronchial tree and lungs examined. Aspiration was characterized as follows: dye leak, ulceration/erosion, hemorrhagic pneumonia, bronchitis/bronchiolitis. Results Of the 14 pigs, one had to be excluded due to accidental cuf delation. Tube sizes were evenly distributed amongst the groups. Cuf pressures were equal: TG 23.7, HL 25.2 – P <0.2. As seen in Table 1, the incidence of microaspiration was signiicantly less for TG in the Blue Dye and bronchitis groups. Table 1 (abstract P229). Incidence of microaspiration Hi-Lo TaperGuard P value Dye leak 7/7 1/6 0.005 Ulceration 5/7 1/6 0.07 Hemorrhagic pneumonia 5/7 1/6 0.07 Bronchitis 5/7 0/6 0.016 Conclusions The TG provided signiicant microaspiration protection compared with the conventional tube in the dye and bronchitis categories. Although not statistically signiicant, the diference in the other two categories may be of clinical signiicance. Further clinical studies are necessary to conirm this point. References 1. 2. Oikkonen M, Aromaa U: Leakage of luid around low-pressure tracheal tube cufs. Anaesthesia 1997, 52:567-569. Rawlinson E, Minchom A: Pulmonary aspiration. Anaesth Intensive Care Med 2007, 8:365-367. P230 A cuf-leak pressure test is a simple method for assessing severe laryngeal edema in postoperative patients H Hayami, S Nagai, S Ohama, A Sakurai, Y Sugawara, H Yamada, O Yamaguchi, Y Koide Yokohama City University Medical Center, Yokohama, Japan Critical Care 2010, 14(Suppl 1):P230 (doi: 10.1186/cc8462) Introduction The cuf-leak test has been proposed as a clinical method for predicting stridor or respiratory distress caused by laryngeal edema Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 following extubation. However, the true incidence of laryngeal edema in postoperative patients is not clear. We assessed the relationship between upper airway obstruction and the values of cuf-leak pressure in postoperative patients. Methods One hundred and ifty-eight postoperative patients (123 elective, 35 emergency) were included. After ventilator weaning was accomplished, we measured the airway pressure at which a sound of cuf leakage was audible by a cuf pressure monitor. In 28 cases, the cuf leak pressure was measured during both awake and sedated states. Results The cuf leak pressure value was 12.8 ± 10.1 (median 10) mmHg for elective cases and 12.6 ± 10.0 (median 10) for emergency cases (NS). Six patients (3.8%) were not extubated because of high leak pressure and the value was 40.5 ± 16.0 (24 to 60) mmHg. One hundred and fortythree patients were extubated and nine of those (6.3%) were diagnosed as laryngeal edema by laryngoscopy. Seven of those (5.0%) needed reintubation, one was for the reason of massive sputa, three were for granuloma formation, and three (2.1%) were diagnosed as severe laryngeal edema. Patients who developed severe laryngeal edema had a higher leak pressure (27.2 ± 22.7 mmHg) than those who did not, and all of such patients had pressure above 20 mmHg. The sensitivity and the speciicity of the test using a threshold value of 20 mmHg for severe laryngeal edema were 97.2% and 40.0%, respectively. The occurrence of severe laryngeal edema was not associated with age, gender, perioperative weight gain, duration of translaryngeal intubation, inner diameter of the endotracheal tube, or serum albumin concentration. However, the cuf leak pressure value >20 mmHg was associated with gender (female, P = 0.02) and inner diameter of the endotracheal tube (P = 0.0017) by multivariate regression. In 28 patients, the cuf leak pressure was 17.8 ± 10.6 during the awake state and 9.9 ± 4.6mmHg under sedative. Because tonus of larynx is considered to be related to cuf leak pressure, it is useful to measure the cuf leak pressure in a sedated state if the patient had a high value in the awake state. Conclusions Cuf leak pressure values <20 mmHg at any time are useful to rule out severe laryngeal edema. It may be useful to measure the pressure in a sedated state if the value in the awake state is high. P231 Code critical airway teams improves patient safety G Sample, P Mccabe, T Vandruf Washington Hospital Center, Washington, DC, USA Critical Care 2010, 14(Suppl 1):P231 (doi: 10.1186/cc8463) Introduction It takes an experienced multiprofessional team to handle emergent airway situations. We created a Code Critical Airway team to manage airway emergencies. Critical (diicult) airway emergencies are increasing due to advances in medical treatments, obesity and sleep apnea. Diicult airway events are low volume and high risk, requiring expert skill and communication. In the United States a leading level I adverse patient safety event is ‘death or serious disability associated with airway management’ [1]. Methods Utilizing a complex framework with the goal of successful airway management outcomes, the project was divided into six components: patient safety, includes the development of an airway management plan focused on improved team eiciency and culture change from Panic Button to Bridge to Safety; patient assessment, includes the development of educational programs focusing on early recognition of potential critical airway patients; teamwork, includes the development of improved communication, paging and handof processes; performance improvement, includes after-action reviews of each event to assess and address system and process issues; equipment, includes the development of standardized airway equipment at the bedside; and team simulation training, includes consistency in communication, handof, teamwork and equipment use. Results The average time to establish an airway across all techniques has been drastically reduced (55 minutes to 22 minutes), of special note is the dramatic improvement in the time to reintubation (18 minutes to 5 minutes). The number of surgical airways required reduced from ive pre-project to zero in phase two. Thirty-one percent of the airway patients were obese or had a short thick neck. We have seen an increase in our respiratory distress calls versus respiratory arrest calls, reinforcing the beneit of proactive over reactive calling. Code Critical Airway education S80 programs improved the number of appropriate Code Critical Airways being called, as well as improved overall Code Critical Airway Team response time. As a by-product of this process, reliability of available appropriate airway equipment is now 100%. Conclusions This project made signiicant process improvements in the areas of patient safety, team communication, equipment availability and response eiciency. Hospitals should develop a specialized airway team to decrease adverse airway events. References 1. 2. Oice of Health Care Quality: Maryland Hospital Patient Safety Program Annual Report Fiscal Year 2006. Annapolis, MD: Oice of Health Care Quality; 2007. Rochlen L, et al.: Proceedings from the Annual Meeting of the American Society Anesthesiologists. Designated Airway Emergency Team May Improve Survival Rates at Hospital Discharge; 17–21 October 2009; New Orleans, LA. P232 A prospective evaluation of hemodynamic indexes to predict weaning from mechanical ventilation in patients after cardiac surgery F Galas, L Hajjar, T Lara, E Nozawa, M Feltrim, M Sundin, R Kalil, J Otavio Heart Institute, São Paulo, Brazil Critical Care 2010, 14(Suppl 1):P232 (doi: 10.1186/cc8464) Introduction Weaning from mechanical ventilation represents an important issue after cardiac surgery because a delayed extubation can burden the patient’s recovery health, increasing the risk of infections and the length of hospital stay. Recognized parameters such as minute ventilation, negative inspiratory force, maximal inspiratory pressure ratio, and Tobin index do not predict very well the success of extubation in these patients. We tested whether hemodynamic parameters and indexes predict better successful extubation after cardiac surgery. Methods We prospectively evaluated 100 patients undergoing cardiac surgery with pump admitted to the InCor ICU and monitored with Swan–Ganz. Exclusion criteria were congenital diseases, transplantation procedures, chronic renal failure, and ejection fraction lower than 20%. Results Patients were considered for extubation if they tolerated a T-piece for 30 minutes. From 100 patients, 88 were successfully extubated and 12 patients failed. There was no diference between groups regarding baseline characteristics, including ejection fraction and co-morbidities. Univariate analysis showed in the successful group a lower duration of pump (55 minutes x 90 minutes, P = 0.038), a lower length of stay in ICU (12 x 32 days, P <0.0001), a lower BNP level (144 x 422, P = 0.002), and a higher PO2/FiO2 (312 x 266, P = 0.043) and a higher VeRT (time recovery minute ventilation) 4 x 2, P <0.01. Multivariate analysis showed high levels of BNP and of PO2/FiO2 at admission are strong predictors of successful weaning. Conclusions After cardiac surgery, lower levels of BNP and higher PO2/ FiO2 are predictors of successful weaning. This suggests that adequate hemodynamic optimization must be achieved in patients to improve outcomes as early weaning of mechanical ventilation. References 1. 2. Epstein SK, et al.: Efect of failed extubation on the outcome of mechanical ventilation. Chest 1997, 112:186-192. Epstein SK: Decision to extubate. Intensive Care Med 2002, 28:535-546. P233 Rapid shallow breathing index predicts readiness to wean? R Janssen-Dean, K Vrints, I Blum, B Speelberg St Anna Hospital Geldrop, the Netherlands Critical Care 2010, 14(Suppl 1):P233 (doi: 10.1186/cc8465) Introduction The rapid shallow breathing index (RSBI) has been shown to be a parameter that predicts successful weaning. A RSBI of less than 105 is a predictor for successful weaning. We investigated whether the RSBI could be a useful parameter in our patient population. Methods From June 2008 until March 2009 all patients who had been mechanically ventilated on our six-bed ICU were studied. Only the patients who were invasively mechanically ventilated, for longer than 6 hours, who had no missing information and did not die whilst on the ventilator were included in this study. RSBIs were measured by these patients at two diferent time points of weaning, irstly at the point of reduction in pressure support and then at the point of extubation. The RSBI was measured using Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 the ventilator (Maquet servo-i) by reducing the pressure support level to zero and adjusting the PEEP to 5 cmH2O. A signiicance level <0.05 was considered signiicant. The nonparametric Kruskall–Wallis test was used to analyse the collected data. Results One hundred and nineteen patients were ventilated over this time period: 74 patients did not meet the inclusion criteria; 45 were included. At the time point of further reduction in pressure support, the RSBI showed signiicant diferences (P = 0.038) between the group who was ready for weaning and the group who was not ready for weaning. In the group with successful reduction of PS (n = 28) the RSBI was 83.54 ± 32.12, and in the group without successful reduction of PS (n = 2) the RSBI was 158.50 ± 38.89. At the point of extubation the RSBI was signiicant in predicting successful extubation (P <0.001). In the group who was successfully extubated (n = 24) the RSBI was 75.25 ± 21.62, and in the group who was unsuccessfully extubated (n = 5) the RSBI was 155.20 ± 25.23. Conclusions At the moment of extubation, the RSBI showed signiicant low values in the successful group. This was also for the time point further reduction in pressure support level. P234 Increasing pressure support during vibrocompression is useful during respiratory therapy? W Naue, A Guntzel, A Silva, R Condessa, R Oliveira, S Vieira Hospital de Clínicas de Porto Alegre, Brazil Critical Care 2010, 14(Suppl 1):P234 (doi: 10.1186/cc8466) Introduction ICU inpatients are susceptible to events of transient hypoxemia. The physical therapist makes use of bronchial hygiene techniques to solve or alleviate this problem. The goal of this paper was to compare two physiotherapy techniques: vibrocompression versus vibrocompression plus increase of 10 cmH2O in inspiratory pressure (IP) during pressure support ventilation (PSV). Methods After being placed in the supine position in bed, with head angle elevation at 30°, patients were randomized to: group 1 (G1): vibrocompression for 10 minutes in the chest, or group 2 (G2): vibrocompression plus increase of 10 cmH2O in IP in PSV for 10 minutes in the chest. Clinical variables and APACHE II score were registered. Parameters analyzed at the beginning (1) and at the end (2) of the protocol were: variation of peak pressure (ΔPP = Pp2 – Pp1), variation of tidal volume (ΔVT = VT2 – VT1), variation of dynamic compliance (ΔCdyn = Cdyn2 – Cdyn1). The amount of variation of mucus secretion aspirated (ΔSa = Sa2 – Sa1) at the end was also measured. The results are showed in mean ± SD. Results Both groups (G1: n = 30 and G2: n = 39) were similar in clinical characteristics and APACHE II score. The variation of variables in G1 and G2, were respectively: ΔPp (cmH2O) = 0.58 ± 1.41 and –0.10 ± 0.98, P = 0.02; ΔVT (ml) = 28.90 ± 119.40 and 64.26 ± 93.82, P = 0.96; ΔCdyn (cmH2O) = 3.03 ± 9.56 and 4.26 ± 8.24, P = 0.89; ΔSa (g) 0.29 ± 1.73 and 0.93 ± 2.28, P = 0.36. Conclusions We found no diferences between groups, except in peak pressure (Pp2 >Pp1) that was greater in G1. This result could be probably due to decreased airway resistance. References 1. 2. Stiller K: Chest 2000, 118:6. Passam F, et al.: Respiration 2003, 70:4. P235 Predicting success in weaning from mechanical ventilation in patients with and without cardiac disease L Cassel, C Hahn, S Vieira Hospital de Clínicas de Porto Alegre, Brazil Critical Care 2010, 14(Suppl 1):P235 (doi: 10.1186/cc8467) Introduction Failure in weaning from mechanical ventilation (MV) is frequent (25 to 30%) and associated with high mortality. Indexes predicting success can be helpful clinically. However their predictive capacity can be low, principally in patients with cardiac disease. The goal of this study is to evaluate weaning predictor indexes in patients with cardiac disease during weaning from MV. Methods We included patients with and without cardiac disease under MV for at least 48 hours, submitted to spontaneous breathing trial (SBT) for 30 minutes, extubated according to clinical decision and followed for S81 48 hours. They were evaluated concerning age, sex, clinical characteristics, length of hospital and ICU stay and of MV. At the irst and 30th minutes from SBT there were analyzed: arterial blood gases, hemodynamic and respiratory parameters as respiratory rate (f ), tidal volume (VT), rapid shallow breathing index (f/VT), maximal inspiratory and expiratory pressures. Comparisons were done between this group of patients and success x failure, deining failure as a return to MV in the irst 48 hours. Results Four hundred and thirteen patients were studied, 81 with cardiac disease and 332 without. Overall mortality rate was 14%. Return to MV occurred in 19.7%. The most important diferences comparing patients with cardiac disease with the control group were: lower mortality rate (21% x 13.5%, P <0.006), shorter length of ICU stay (9 ± 3 x 16 ± 13 days). Comparing patients who failed in the weaning process with and without heart disease (20% x 20%, P <0.55). Comparing f/VT in 30th minute of patients who have had success with those who failed the weaning process (60 ± 38 x 74 ± 47, P <0.012), a lower increase in f/VT (Δf/VT) (4 ± 27 x 11 ± 33, P <0.075) during the test. Conclusions In this group of patients a great number failed in the weaning process, showing, as expected, a higher mortality rate. Parameters most related to failure in the literature were higher age, longer length of ICU stay, mortality and f/VT. In this study, just the last parameter was sensitive principally in the 30th minute, and higher increase in f/VT (Δf/VT) during the test, demonstrating that patients with cardiac disease not fail more than others during the weaning process, as well as the eiciency of the test to predict success in weaning. Members of Weaning Study Group R Wickert, LG Borges, ME Alves, ACT Silva, R Condessa, MB Blom, R Zancanaro, F Callefe, KB Pinto, K Hartmann, P Pinheiro, ES Oliveira, C Trevisan. References 1. 2. Frutos-Vivar F, et al.: Chest 2006, 130:1664-1671. Tanios MA, et al.: Crit Care Med 2006, 34:2530-2535. P236 Implementation of a standardised weaning protocol in patients with prolonged mechanical ventilation in a post-acute care ICU K Schneider1, F Oehmichen1, M Pohl1, M Ragaller2 1 Bavaria Klinik Kreischa, Germany; 2University Hospital Dresden, Germany Critical Care 2010, 14(Suppl 1):P236 (doi: 10.1186/cc8468) Introduction Due to the improvement of nearly all ields of acute care in the past decades, the burden of long-term dependency from mechanical ventilation (MV) increases incessantly. The aim of this study was to implement and test a standardised weaning protocol in patients sufering from long-term mechanical ventilation. Methods After approval by the local ethics committee and informed consent, 644 patients were enrolled in a prospective cohort study in 1 year. The mean time on the ventilator before inclusion was 39.4 (6 to 357) days. The reasons for long-term MV were: cerebral 33.1%; cardiovascular 31.5%; pulmonary 28.7% and 5.6% neuromuscular diseases. The weaning protocol started with 6 x 5 minutes spontaneous breathing (intermission of mechanical ventilation) on day 1 and was increased stepwise up to 24 hours spontaneous breathing on day 22. If there was no improvement in weaning steps over 5 days or there were more than three steps backwards the patient was switched to the individual weaning approach. The weaning protocol was carried out by the previously trained ICU staf as well as by specialized physiotherapists. Results A total of 77.3% (n = 498) of the patients could be weaned of the ventilator by the irst efort. Out of these, 85.9% of the patients were weaned by the protocol whereas 14.1% needed an individual approach. The mean time of weaning was 17 (5 to 67) days using the protocol and 29 (1 to 88) days due to the individual approach. In 12.6% both weaning procedures failed and these patients were discharged from the hospital into a home-care ventilation program. In total, 10.1% of the patients died on mechanical ventilation during their ICU stay. Patients who had needed a second weaning efort (n = 111) were weaned in 36.4% by the protocol, transferred to home-care ventilation (28.8%) or died (35.1%). Conclusions Using the standardised weaning protocol, more than three-quarters of the prolonged mechanically ventilated patients could be weaned of the ventilator in a mean of 17 days. Only 14.1% needed an individual strategy that takes 29 days until complete release from the ventilator. Therefore we suggest this kind of weaning protocol as a useful Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 tool in patients with prolonged mechanical ventilation in a post-acute care facility. References 1. Scheinhorn DJ, et al.: Chest 2001, 119:236-242. P237 Comparison of pressure control and pressure support modes for non-invasive mechanical ventilation in acute hypercapnic respiratory failure M Aydogdu, G Gursel, F Yıldırım, S Tasyurek, F Aykan, G Teksut, S Nazik, A Demir Gazi University Medical Faculty, Ankara, Turkey Critical Care 2010, 14(Suppl 1):P237 (doi: 10.1186/cc8469) Introduction Non-invasive positive pressure ventilation (NIPPV) has generally been accepted as beneicial to use in acute hypercapnic respiratory failure (AHcRF), but it is not still standardized how to perform it, and with which ventilation modes. In this study it was aimed to compare the eiciency of pressure control (PCV) and pressure support ventilation (PSV) modes on patients with AHcRF. Methods A prospective randomized controlled study, performed in a pulmonary ICU of a university hospital. Patients who were admitted with the diagnosis of AHcRF were included in the study consecutively and they were randomized to have either NIPPV with PSV or PCV for the irst 2 hours. Then NIPPV was stopped for 4 hours to achieve a basal PaCO2 level, and after this waiting period NIPPV was continued with the other mode. The mode that leads to a greater decrease in PaCO2 value was accepted as the successful mode. Results A total of 40 patients with mean age of 69 ± 12 years were included in the study. In only two (5%) patients were endotracheal intubation and mechanical ventilation needed. Among them, only one (2.5%) patient died. After NIPPV there was a signiicant decrease in PaCO2 level with both PSV and PCV modes. But when ΔPaCO2 (PaCO2 after NIPPV – PaCO2 baseline) of both groups was compared, no statistically signiicant diference was identiied. Among the 20 patients that NIPPV was started with PSV, in nine (45%) of them PSV was assessed as successful and continued; in 11 of them (55%) NIPPV was switched to PCV (P >0.05). Among the 20 patients in which NIPPV was started with PCV, in one of them NIPPV was unsuccessful ending up with intubation, in 16 of them PCV (84%) was successful (P = 0.051). The presence of apnea and apnea plus hypopnea with the initial mode was found as the factor afecting the assessment of PCV as the successful mode (P <0.05). Conclusions Both PSV and PCV can be used eiciently in the treatment of AHcRF of various causes. But in the presence of apneas and hypopneas (either central or obstructive) PCV can be preferred instead of PSV. P238 Non-invasive CPAP with face mask: comparison between diferent devices A Galimberti, G Mistraletti, F Rapido, M Gomarasca, B Salihovic, L D’Amato, T Crespi, C Reali Forster, P Spanu, G Iapichino Università degli Studi di Milano, Milan, Italy Critical Care 2010, 14(Suppl 1):P238 (doi: 10.1186/cc8470) Introduction This study compared the reliability and the eicacy of three diferent non-invasive CPAP systems, Ventumask® low low (LF), Ventumask® high low (HF) and Boussignac® CPAP valve (B), both in a lung model and in healthy subjects. Methods Lung model: pneumatic simulator irst set at respiratory rate 16/ minute with 400 ml tidal volume (L1), then RR 40/minute with 800 ml tidal volume (L2). Human study: 10 healthy subjects were asked to make an expiratory pause (T1), ive breaths at tidal volume (T2), and a short sequence of tachypnea (T3). The diferences between set and efective PEEP and FiO2 were used as indexes of reliability. The minimum airway pressure below the PEEP level and the airway pressure swing around PEEP were used as indexes of eicacy. In the lung simulator protocol, the pressure–time product was measured and then correlated to the other eicacy indexes. Results Lung model: HF showed a tendency towards a more stable PEEP (P = 0.067). In B a signiicant fall in the FiO2 value from L1 (96.9 (95.5; 97.6)%) to L2 (54.2 (50.4; 56.9)%) was observed (P <0.001). The airway pressure swing around PEEP was greater in LF and B compared with HF in L1 (P <0.001), while S82 during L2 it was lower in B (P = 0.007). The pressure–time product was better described by the airway pressure swing around PEEP (r2 = 0.95) rather than the minimum airway pressure below the PEEP level (r2 = 0.85). Human study: a lower diference between set and efective FiO2 was registered with HF (P <0.001). Ventumask® systems showed an overall higher minimum airway pressure below the PEEP level compared with B (P <0.001). During T3, HF (+10.1 (+7.4; +13.2) cmH2O) showed a smaller airway pressure swing around PEEP relative to LF (+11.9 (+10.1; +16.6) cmH2O, P <0.001) but not to B (+12.2 (+6.6; +15.1) cmH2O, P = 0.40). During the whole respiratory sequence, an increase in end-expiratory pressure was observed. This increase was greater in B valve than in HF and LF (P <0.001). Conclusions According to observations, HF seemed to be the most reliable device. In conditions of high low demand, B reached FiO2 values lower than expected. The dynamic hyper-pressurization, higher with B, is probably due to the relationship between expiratory low and the resistance ofered by the expiratory valve. B, even if handy and lightweight, is less reliable in terms of low supply and PEEP stability. P239 Efects of non-invasive mechanical ventilation on hemodynamic and gas exchanges parameters after cardiac surgery in patients with 300 >PaO2/FiO2 >150 A Preisig1, VB Lagni1, V Almeida1, EA Lucio1, SR Vieira2 1 Irmandade da Santa Casa de Porto Alegre, Brazil; 2Hospital de Clínicas de Porto Alegre, Brazil Critical Care 2010, 14(Suppl 1):P239 (doi: 10.1186/cc8471) Introduction Non-invasive mechanical ventilation (NIV) has been used in hypoxic postoperative cardiac patients but more studies are necessary to clarify its respiratory and hemodynamic efects. Therefore, our objective was to study its efects in the oxygenation index (PaO2/FiO2) and in hemodynamic variables in this group of patients. Methods This is a randomized trial in which all postoperative cardiac patients having a pulmonary artery catheter and showing a PaO2/FiO2 between 150 and 300 (with FIO2 0.31), 1 hour after extubation, were included. The intervention group used NIV with a bilevel positive airway pressure (an inspiratory pressure to generate a tidal volume of 6 ml/kg and an expiratory pressure of 7 cmH2O) with FIO2 0.4 during 3 hours. The control group used oxygen by Venturi mask in order to keep good oxygenation. In both groups, measurements were done in a basal situation (FiO2 0.31), in the irst hour after beginning the treatment (FiO2 0.4) and 1 hour after the end of the intervention (FiO2 0.31). Variables studied included: pH, PaO2, PaCO2 and PaO2/FiO2 ratio, heart rate (HR), mean arterial pressure (MAP), pulmonary capillary wedge pressure (PCWP), central venous pressure (CVP), mean pulmonary arterial pressure (MPAP) and cardiac output (CO). Results Forty-two patients were included in the study period. The mean age was 65.7 ± 10 years. The basal variables were similar in the two groups. There was an increase in the PaO2/FiO2 ratio in the NIV group in the irst hour (P <0.05, 95% CI 74.8 to 6.6) and 1 hour after stopping the treatment (P <0.05, 95% CI 90.7 to 10.8) compared with the control group. There were no signiicant changes in hemodynamic parameters, pH and PaCO2 during NIV compared with the control group. Conclusions There were no changes in hemodynamic variables during the NIV period. However, these results suggest that NIV improved oxygenation even 1 hour after stopping the treatment. References 1. 2. 3. 4. Zarbock A, et al.: Chest 2009, 135:1252-1259. De Santo LS, et al.: J Thorac Cardiovasc Surg 2009, 137:342-346. Kindgen-Milles D, et al.: Chest 2005, 128:821-828. Matte P, et al.: Acta Anaesthesiol Scand 2000, 44:75-81. P240 Non-invasive positive pressure ventilation in burns J Haddad, A Mokline, I Rahmani, H Oueslati, I El Jami, K Brini, K Bousselmi, A Messadi Burn and Trauma Center, Tunis, Tunisia Critical Care 2010, 14(Suppl 1):P240 (doi: 10.1186/cc8472) Introduction Acute respiratory failure is a common complication of severely burn-injured patients. Non-invasive positive pressure ventilation Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 (NIPPV) has been used with success in hypercapnic and hypoxaemic acute respiratory failure. However, the outcome of NIPPV with burn patients is less well documented. The purpose of this study is to report our experience with NIPPV in a series of burn-injured patients. Methods The records of all burn patients from July 2008 to September 2009, in whom NIPPV was used in the intensive burn care unit, were reviewed. The criteria for selecting patients for NIPPV included a combination of the following factors: patients with acute respiratory failure, haemodynamically stable, conscious and cooperative with their treatment. There had to be no need for endotracheal intubation. Results Thirty-one patients were treated with NIPPV. Nineteen were female. Mean age was 44.22 years, mean total body surface area (TBSA) was 38.37%. NIPPV was used to treat hypoxia in 21 patients, hypercapnia in four patients and both of them in six patients. The mean PaO2/FiO2 ratio before NIPPV was 188.53. NIPPV was used to treat ARDS in 12 patients, pneumonia in eight patients, atelectasis in six patients and cardiogenic oedema in ive patients. The mean PaO2/FiO2 ratio after NIPPV was 256.43. Intubation was successfully avoided in 12 out of the 31 (38.7%) patients. All of these patients progressed to self-ventilation status following NIPPV. Conclusions The use of NIPPV with burn-injured patients is, as yet, unclear because little work has been documented. In our experience, the use of NIPPV can lead to avoid the need for endotracheal intubation and mechanical ventilation. Reference 1. Smailes ST: Burns 2002, 28:795-801. P241 Non-invasive mechanical ventilation in the weaning process: continuous hemodynamic monitoring F Franchi, C Palomba, E Mastrocinque, L Cubattoli, P Mongelli, E Casadei University of Siena, Italy Critical Care 2010, 14(Suppl 1):P241 (doi: 10.1186/cc8473) Introduction The purpose of this prospective study is to describe the hemodynamic and cardiac variation during a trial of non-invasive ventilation (NIV) in the process of weaning from ventilatory support. A continuous hemodynamic monitoring was performed with a pulse contour method, the MostCare (Vytech Health, Laboratoires Pharmaceutiques Vygon, Ecouen, France). This device could be used to identify the early warnings of cardiovascular dysfunction, which may contribute to unsuccessful weaning. Methods Fourteen patients, admitted to our ICU between January and July 2009, were included in the study: six intubated on respiratory failure due to cardiogenic pulmonary edema (CPE; 52 ± 18 years, four male (M), two female (F)), eight intubated on chronic obstructive pulmonary disease (COPD; 71 ± 16 years, four M, four F). The NIV trial was performed with a face mask: pressure support (PS) = 5 to 10 cmH2O, positive endexpiratory pressure (PEEP) = 5 to 7 cmH2O. Cardiovascular variables and gas exchange data were measured at three deined points in time: 1 hour before the extubation (T1), continuously during the NIV trial (a mean value was calculated and expressed as T2), and at the end of the NIV trial with the patient in spontaneous breathing (T3). Results The variation of cardiac index (CI) was: T1 2.53 ± 0.43 ml/minute/m2 CPE vs 3.2 ± 0.64 ml/minute/m2 COPD; T2 2.93 ± 0.93 ml/minute/m2 CPE vs 2.9 ± 1.33 ml/minute/m2 COPD; T3 1.96 ± 0.61ml/minute/m2 CPE vs 3.3 ± 1.37 ml/minute/m2 COPD. The variation of CI depended on the variation of stroke volume (SV), while the heart rate (HR) did not change during the trial. We calculated the oxygen delivery (DO2) by the correlation of CI and gas exchange: T1 767 ± 218 ml/minute CPE vs 839 ± 134.3 ml/minute COPD, T2 917 ± 417 ml/minute CPE vs 701 ± 349 ml/minute COPD, T3 760 ± 404 ml/minute CPE vs 753 ± 340 ml/minute COPD. The variation of CI and DO2, observed within and among the two groups was never signiicant. Conclusions Both groups of patients were successful in achieving spontaneous ventilation. In our opinion, continuous hemodynamic monitoring may provide helpful beat-to-beat information and it might be used, combined with the gas exchange and oxygen saturation monitoring, during the weaning process as a predictor of cardiovascular instability or respiratory failure. Moreover, continuous hemodynamic monitoring enables one to be aware of the variation of systemic oxygen delivery, and these data could be used to value critically ill patients during the weaning process. S83 P242 Inluence of severe obesity on non-invasive ventilation strategies and responses in patients with acute hypercapnic respiratory failure in ICU G Gursel1, M Aydogdu1, G Gulbas2, S Ozkaya3, S Tasyurek1, F Yıldırım1 1 Gazi University Medical Faculty, Ankara, Turkey; 2Inonu University Medical Faculty Pulmonary Diseases Department, Malatya, Turkey; 3Rize University Medical Faculty Pulmonary Diseases Department, Rize, Turkey Critical Care 2010, 14(Suppl 1):P242 (doi: 10.1186/cc8474) Introduction Obesity rates are increasing in the general population and it is also prevalent in ICUs. Patients are sometimes admitted to ICUs for hypercapnic respiratory failure or cor pulmonale but in general they are admitted for pneumonia, excessive daytime sleepiness, heart failure, COPD or asthma attacks or pulmonary embolism; and hypercapnic respiratory failure is noticed during this period. On the other hand, optimal non-invasive mechanical ventilation strategy is not known during their ICU treatment. The aim of this study is to assess the diferences between NIV strategies and outcomes between obese and nonobese patients with acute hypercapnic respiratory failure. Methods In this retrospective cohort study, 73 patients were studied and all of them were ventilated with a face mask. Patients divided into two groups as obese (BMI >35 kg/m2) and nonobese (BMI <35 kg/m2), and whether necessary pressure, volume, mode, ventilator and time to reduce PaCO2 below 50 mmHg were signiicantly diferent in obese and nonobese patients was investigated. Results Mean age of the patients was 66 ± 14 years and mean admission APACHE II score was 18 ± 4; 41 (56%) of them were female. ICU admission reasons for the obese patients were signiicantly more frequently pulmonary edema and less frequently pulmonary infections (P = 0.003 and 0.043, respectively) than the nonobese patients. While there were no signiicant diferences across the groups between the ventilators, modes, and inspiratory pressure levels, obese patients required higher end-expiratory pressure levels and more time to reduce the PaCO2 level below 50 mmHg than the nonobese group. Length of NIV and ICU stay, intubation and the mortality rate were similar across the groups. Conclusions These results suggest that improvement of hypercapnia in obese patients may require higher PEEP levels and longer times than the non-obese ones during acute hypercapnic respiratory failure attack. P243 A simple predictive scoring system for prolonged mechanical ventilation in severe sepsis and septic shock N Saito, Y Sakamoto, K Mashiko Chiba Hokusou Hospital, Nippon Medical School, Chiba, Japan Critical Care 2010, 14(Suppl 1):P243 (doi: 10.1186/cc8475) Introduction Prolonged mechanical ventilation (MV) is associated with high morbidity and mortality in septic patients. However, limited data are available on the prediction of prolonged MV. We conducted an observational cohort study aimed at developing a prolonged MV predictive scoring system for severe sepsis and septic shock. Methods We retrospectively analyzed 120 consecutive patients with severe sepsis or septic shock who were ventilated for more than 72 hours between January 2005 and October 2009. Clinical features and physiologic parameters were examined for more than 15 days for use as predictors of MV. Patients were divided into two groups: group 1, those requiring MV for <15 days; group 2, those requiring MV >15 days. Results The mean (± SD) age and SOFA scores were 65.3 ± 16.7 years and 10.0 ± 3.9, respectively, and 35% required prolonged MV. Univariate analysis indicated that the length of ICU and hospital stays, hospital mortality, the rate of transfusion, incidence of ARDS, ventilator-associated pneumonia (VAP), other nosocomial infection (NI) and drug-resistant bacteria, the ratio of steroid therapy and muscle relaxant use, and the mean PaO2/FiO2 ratio during the irst 3 days after admission were signiicantly diferent between the two groups. The independent predictors for prolonged MV were ARDS (OR 5.24 (P = 0.001; 95% CI: 1.9 to 14.1)), VAP (OR 7.75 (P <0.001; 95% CI: 2.7 to 22.0)), and transfusion (OR 2.84 (P = 0.036; 95% CI: 1.0 to 7.5)) Using these results, we were able to develop a prolonged MV predictive scoring system. This simpliied clinical risk assessment tool was developed from Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 the results of univariate and multivariate analysis, with scoring based on a cut-of point related to the adjusted odds ratio. Prolonged MV score: VAP = 7 points; ARDS = 5 points; transfusion = 2 points; incidence of drugresistant bacteria, steroid therapy, muscle relaxant use, other NI, the mean PaO2/FiO2 ratio during the irst 3 days after admission <220 = each 1 point. The area under the receiver operating characteristic curve for prolonged MV in this scoring system was 0.866 (P <0.001; 95% CI: 0.802 to 0.931). Conclusions The simple predictive scoring system for prolonged MV in severe sepsis/septic shock developed here will therefore help in planning the long-term care of such patients. P244 Simpliied approach to ICU severity scoring with MPM and EUROSCORE JH Reeves, JA Barrett, G Hawdon, F Hawker Cabrini Hospital, Malvern, Australia Critical Care 2010, 14(Suppl 1):P244 (doi: 10.1186/cc8476) Introduction Severity scoring is a powerful tool for quality control in the ICU. We introduced a new severity scoring system to our ICU. The aim of this report is to describe the database and present the results of the irst 12 months. Methods We analysed needs for database and severity scoring. We chose on-admission scoring with EUROSCORE for cardiac surgical patients, and Mortality Prediction Model II time zero for other patients. Data were collected via highly simpliied forms onto a spreadsheet. Demographic entry was by ward clerk, on-admission severity scoring was by resident medical staf, and risk of death calculation and data cleaning was by senior attending medical staf. Individual patient risk of death was presented as a logit. Combined risk of death for the whole cohort was calculated from the arithmetic mean of individual logits. We estimated the time to completion of each step in data acquisition to calculate a total time spent per patient. Results There were 1,355 admissions, mean (SD) age 69.2 (15.9) years, 57.1% male; median (range) length of stay 23.1 (1.7 to 1,882.5) hours. Fiftyfour per cent of patients were ventilated for a median (range) 7.5 (0.8 to 1,877) hours. Predicted mortality for cardiothoracic and noncardiothoracic patients combined was 8.64% and the observed mortality was 2.8%. EUROSCORE-predicted mortality for the 535 cardiothoracic patients was 5.72% and the observed mortality was 0.75% (four patients). MPMpredicted mortality for the 820 noncardiothoracic patients was 11.23% and the observed mortality was 4% (34 patients). Estimated time to complete the severity scoring form was 30 seconds, to enter a new patient on the database was 90 seconds and to calculate risk of death and check data integrity was 90 seconds. Total was 3.5 minutes per patient. Conclusions Data collection/analysis is essential for quality management in the ICU. Proprietary systems are expensive. Traditional scoring systems (APACHE II) are poorly calibrated to some case mixes. To overcome these problems, we devised a simple, inexpensive and highly valuable ICU database. The key features were well calibrated, on-admission severity scoring, highly simpliied forms, a basic spreadsheet and collaborative staf involvement. Senior medical staf performed the inal data checking. The project provided abundant high-quality data with a total input of 3.5 minutes per patient. We are trialling the database in a large ICU in China and we would welcome input from other ICUs that would like to copy our methods. P245 Validation of a computerised system to calculate the sequential organ failure assessment score C Bourdeaux1, M Thomas2, T Gould2, Z Evans2, D Bryant2 1 Frenchay Hospital, Bristol, UK; 2Bristol Royal Inirmary, Bristol, UK Critical Care 2010, 14(Suppl 1):P245 (doi: 10.1186/cc8477) Introduction The sequential organ failure assessment (SOFA) score was introduced with the aim of quantifying the severity of illness, based on organ dysfunction, serially over time. A previous study has suggested that S84 the reliability and accuracy of SOFA scoring by intensive care physicians is good but there may be room for improvement [1]. Manual calculation of the score can be time consuming. We developed a computer program that derives a SOFA score from the electronic patient record, the Innovian system (Draeger, Germany). To date, no automated method for SOFA score calculation has been validated. We validated the automated SOFA score collection method in order to assess its accuracy and reliability. We also measured the time for manual collection of SOFA scores in order to assess the resource saving potential of the computer system. Methods Fifty patient records were selected from the database as a stratiied random sample in order to represent the patient population of our teaching hospital adult ICU. Two ICU physicians calculated a total SOFA score and an individual organ score on each of the 50 patient records. A gold standard SOFA score was then generated after discussion between the two physicians with the aid of a third adjudicating ICU physician. SOFA scores generated by the computer were compared with the gold standard to assess accuracy. Reasons for inaccurate scoring were recorded. Results SOFA scores varied from 1 to 15 in this sample, the mean SOFA score for the Gold standard was 8.1 and the standard deviation was 2.9. The agreement between the diferent ratings was very good. The computer score had a better agreement with the gold standard score (Pearson correlation coeicient 0.92), compared with the individual physician scores (Pearson correlation coeicient 0.890 and 0.895). The computer calculated the SOFA score correctly in 41 cases and the physicians calculated the SOFA score correctly in 32 cases. The average time to calculate a SOFA score was 4.91 minutes and was not signiicantly diferent between the physicians. Conclusions The results show that this computer system is highly accurate at calculating SOFA scores from the electronic patient record and is more accurate than physicians. The time saved is considerable. Reference 1. Arts DGT, de Keizer NF, Vroom MB, de Jonge E: Reliability and accuracy of Sequential Organ Failure Assessment (SOFA) scoring. Crit Care Med 2005, 33:1988-1993. P246 Sequential Organ Failure Assessment scores and mortality C Borni, L Meynaud-Kraemer, G Laplatte, HL Lessire CH Pasteur, Colmar, France Critical Care 2010, 14(Suppl 1):P246 (doi: 10.1186/cc8478) Introduction In 2005, in a multicenter study in 79 ICUs in Spain, Cabré and colleagues [1] found patients older than 60 years and with SOFA score higher than 9 for at least 5 days unlikely to survive, suggesting that it could provide a basis for deciding whether to withhold or withdraw life support. We tried to control their hypothesis in our patient population. Methods We reviewed the data of the patients older than 60 years and with a LOS higher than 5 days admitted to our ICU in 2007. We calculated the daily SOFA score of the patients with an initial SOFA score higher than 9. IGSII, LOS and mortality were compared between patients with a SOFA score higher than 9 for at least 5 days (SOFA(+) group) and the other selected patients (SOFA(–) group). Results In 2007, 430 patients were admitted to our ICU. One hundred and forty were older than 60 years and remained more than 5 days in the ICU. Eleven of these patients had a SOFA score higher than 9 during 5 days or more. In the SOFA(+) group, LOS (22.6 ± 13.1 vs 10.8 ± 6.9 days) and mortality (55% vs 33%) are signiicantly higher (P <0.05). The mortality of 55% is in good agreement with the predicted IGSII mortality but far less than the 100% predicted by Cabré and colleagues. Conclusions A SOFA score higher than 9 for at least 5 days in patients older than 60 years seems useless to deine futility in our patient population. It is applicable to only less than 3% of the 430 patients admitted in 2007. The mortality rate of the SOFA(+) group increased but remained far from values permitting to withdraw or withhold intensive care. A weakness of the use of sequential SOFA score to predict outcome is that some therapeutic options can inluence the value of the SOFA score. Reference 1. Cabré L, et al.: Intensive Care Med 2005, 31:927–933 Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S85 P247 Bacteremia, APACHE II and need for renal replacement therapy are independent predictors of mortality in critically ill transplanted patients with cirrhosis C Karvellas1, F Pink2, M McPhail2, G Auzinger2, W Bernal2, I Eltringham2, J Wendon2 1 University of Alberta, Edmonton, Canada; 2King’s College Hospital, London, UK Critical Care 2010, 14(Suppl 1):P247 (doi: 10.1186/cc8479) Introduction Our objective was to determine what physiological and biochemical factors predict development of bacteremia in transplanted cirrhotic patients (TP) and, upon diagnosis of bacteremia, what is the natural history of bacteremic patients (BTP) versus controls (TP). Methods Data collected prospectively and entered into a dedicated physiology database for all transplanted cirrhotic patients admitted to a specialist liver intensive therapy unit (LITU) were examined from January 2003 to July 2005 for incidence of bacteremia and survival. Results In total, 362 patients were transplanted for decompensated cirrhosis (64% elective, 36% in-hospital). Thirty-eight (10%) sufered bacteremia (BTP) while 324 (90%) patients did not (TP). Forty-nine per cent of isolates were Gram-positive organisms, 45% Gram-negatives and 6% fungemia. Median time to irst bacteremia was 11.5 days. On admission (univariate), BTP patients had signiicantly higher APACHE II scores (23 vs 11, P <0.001), worse acidosis (pH 7.27 vs 7.35, P <0.001) and greater degrees of encephalopathy (GCS 12 vs 15, P <0.001). During their LITU course BTP patients had signiicantly greater requirements for renal replacement therapy (RRT) (68% vs 17%, P <0.001), mechanical ventilation (median 15 days vs 2 days, P <0.001) and a longer median LITU stay (21 vs 3 days, P <0.001). Survival to hospital discharge was worse in the BTP group (55% vs 95%, P <0.001). Multivariate analysis (logistical regression) was performed modelling with APACHE II. APACHE II (odds ratio 1.06), bacteremia (4.01) and requirement for RRT pre or post transplant (12.5) were independent predictors of mortality. The APACHE II model performed well (AUROC 0.817). Conclusions In transplanted cirrhotic patients, bacteremia was associated with increased severity of illness on admission, greater requirements for organ support and independently adversely impacted on survival. Higher APACHE II score and the requirement of RRT during LITU stay were also independently predictive of mortality. P248 External validation of six mortality prediction systems for intensive care unit patients M Verhofstad1, T Timmers2, LP Leenen2, KG Moons3 1 St Elizabeth Hospital, Tilburg, the Netherlands; 2Universitair Medical Centre Utrecht, the Netherlands; 3Julius Centre for Health Sciences and Primary Care, Utrecht, the Netherlands Critical Care 2010, 14(Suppl 1):P248 (doi: 10.1186/cc8480) Introduction This study investigates the prognostic quality of six prediction models (APACHE II score, SAPS II, SAPS II (Expanded), SAPS 3, MPM and MPM II0) for assessment in an adult surgical ICU in the Netherlands. Methods Of all single admissions to the surgical ICU of the St Elisabeth Hospital between 1995 and 2000, data to calculate the results of six prediction models were prospectively documented. To evaluate discrimination and calibration, receiver operating characteristic (ROC) curves, area under the characteristic (AUC) curve and the Hosmer– Lemeshow goodness-of-it test were performed. Results The data of 1,821 patients were applied to all six models. Accurate overall mortality prediction was found for the APACHE II, SAPS II, SAPS 3 and MPM models. Discrimination was best for the SAPS 3 model and worst for the APACHE II and MPM models with AUC of 0.81, 0.77 and 0.77, respectively (Figure 1). Calibration was poor for the six prediction systems, varying between 23 (SAPS 3) and 233 (SAPS II (Expanded)). Conclusions The SAPS 3 prediction mortality model is the best validated model for a Dutch surgical ICU population of six models tested. The other general prognostic models for ICU patients underestimate the risk of dying. Figure 1 (abstract P248). Receiver operating characteristic curves for all six prediction models. P249 Prognostic accuracy of severity score for prolonged ICU length of stay >72 hours in general surgical ICU: a prospective study S Kongsayreepong, N Lomarat, S Thamtanavit Siriraj Hospital, Mahidol University, Bangkok, Thailand Critical Care 2010, 14(Suppl 1):P249 (doi: 10.1186/cc8481) Introduction Prolonged ICU stay is associated with high morbidity, mortality and costs [1,2]. Prediction of this prolonged stay will provide information for physician and family and help with resource allocation. Even though, available severity scoring system ie. APACHE II, APACHE III, MPM, SAPS II, MODS scores are widely accepted for evaluating outcomes in the ICU population. But these models might be inaccurate when apply to subpopulation and might not predict prolonged length of stay. The objective of this study was to reine ASA physical status and ive severity scores (APACHE II, APACHE III, SOFA, SAPS, MOFS) in order to predict prolonged length of stay in the adults patients admitted to the general surgical ICU. Methods This prospective observational study was done in 948 adult surgical patients admitted to the general surgical ICU at Siriraj Hospital during 1 January 2005 to 31 December 2005. A prolonged length of stay was deined as staying in the ICU >72 hours. Preoperative ASA physical status and ive severity scores as APACHE II, APACHE III, SOFA, SAPS, MOFS on day 1 were registered and calculated. We analyzed the relationship of each severity score and outcome as prolonged ICU length of stay. Results Prolonged length of stay represented 20.1% of ICU admissions. Among severity scores, ASA physical status IV (P <0.001), emergency ASA (P <0.001), APACHE III (P = 0.025) were signiicantly associated with prolonged ICU length of stay (>72 hours) while MODS was most likely associated with this prolonged length of stay (P = 0.059). From multivariate analysis, only ASA physical status IV (OR 6.503 (2.314 to 18.275), P <0.001) and emergency ASA (OR 4.52 (2.86 to 7.12), P <0.001) were signiicantly associated with prolonged ICU length of stay (>72 hours). Conclusions The study was conducted in 948 adult surgical patients admitted to the general surgical ICU at a 3rd referral university hospital. Among all of the severity scores, ASA physical status IV and emergency ASA were signiicantly correlated with prolonged ICU length of stay >72 hours. References 1. 2. Halpern NA, Betts L, Greenstein R: Federal and nationwide intensive care units in health care costs: 1986–1992. Crit Care Med 1994, 22:2001-2007. Arabi Y, Venkatesh S, Haddad S, Al Shimemeri A, Al Malik S: A prospective study of prolonged stay in the intensive care unit: predictors and impact on resource utilization., prospective, mixed ICU, >14 days. Int J Qual Health Care 2002, 14:403-410. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S86 P250 Perioperative scores to predict mortality in surgical oncologic patients: a review of 1,362 cases C Simoes1, L Hajjar2, M Carmona1, F Galas1, J Auler Jr1 1 Instituto do Cancer do Estado de São Paulo, Brazil; 2Heart Institute, São Paulo, Brazil Critical Care 2010, 14(Suppl 1):P250 (doi: 10.1186/cc8482) Introduction Surgical outcomes depend on many factors, including baseline characteristics and diferences in surgical and anesthetic practices. Few data are available in general surgical oncological patients. We aimed to evaluate the predictive value of Porthsmouth POSSUM and American Society of Anesthesiologists (ASA) scores in oncologic patients submitted to surgical procedures. Methods Data were collected from a database illed with demographic characteristics, neoplasm deinitions, co-morbidities and data from intraoperative room and hospital mortality. The predicted mortality risk was calculated using Porthsmouth POSSUM and ASA physical status grading. Results From 1,362 surgical patients, the observed general hospital mortality was 2.34%. ASA grading underestimated the mortality for low-complexity patients, overestimated in patients with severe systemic disease (ASA III), and was a strong predictor of mortality in patients with life-threatening conditions (ASA IV) (Table 1). On the other hand, the Porthsmouth POSSUM scoring system overestimated mortality in all groups (Table 2). Table 1 (abstract P250). Observed and predicted mortality of oncologic patients evaluated through ASA physical status grading controversially. The aim of our study was to directly compare these scores in the setting of an ED on a cohort of patients with suspected infection. Methods Patients with suspected severe infection from which blood cultures were taken were included in the study. Procalcitonin (PCT) levels were determined, and APACHE II, MEDS and SOFA scores were calculated at admission. Endpoints were 28-day-mortality and necessity for therapy on an ICU. Receiver operating characteristic (ROC) curve analysis was performed to compare the ability of the three scores to predict the endpoints. Results We analyzed 211 patients. Eighty-two patients (43.6%) had a PCT value ≥2 ng/ml and were considered septic. Mean values of APACHE II, MEDS and SOFA score were 16.1 ± 8.5, 7.4 ± 4.7, and 3.4 ± 3.1 respectively. Tables 1 and 2 show the area under the curve (AUC) values of the ROC curves for mortality (Table 1) and ICU therapy (Table 2). Table 1 (abstract P251). ROC analysis for mortality Score AUC Standard error Signiicance APACHE II 0.804 0.045 <0.001 MEDS 0.785 0.048 <0.001 SOFA 0.708 0.051 0.006 Table 2 (abstract P251). ROC analysis for ICU therapy Score AUC Standard error Signiicance APACHE II 0.757 0.038 <0.001 Observed Predicted MEDS 0.648 0.042 0.001 209 4 (1.91%) 1 (0.05%) SOFA 0.731 0.039 <0.001 867 10 (1.15%) 1 (0.4%) ASA III 247 7 (2.83%) 11 (4.5%) ASA IV 39 11 (28.2%) 10 (25%) 1,362 32 (2.34%) ASA Number ASA I ASA II Total Table 2 (abstract P250). Observed and predicted mortality of oncologic patients evaluated through Portsmouth POSSUM scoring Number 0 Observed Predicted 0 to 5 0 0 (3.1%) 5 to 30 1,055 15 (1.42%) 142 (13.5%) 30 to 100 307 17 (5.53%) 149 (48.7%) 0 to 100 1,322 32 (2.34%) Conclusions In surgical oncologic patients, Porthsmouth POSSUM and ASA are not good predictors of mortality. These data suggest that a more sensible and speciic score is needed in this population. Reference 1. Wakabayashi H, et al.: Int J Surg 2007, 5:323-327. P251 Scoring patients with a suspected infection in the emergency department (ED): comparison of the ED-speciic MEDS score with APACHE II and SOFA score J Wilhelm, S Hettwer, D Hammer, M Schürmann, M Amoury, H Ebelt, K Werdan University Hospital Halle (Saale), Germany Critical Care 2010, 14(Suppl 1):P251 (doi: 10.1186/cc8483) Introduction Several scores exist for characterization of critically ill patients, developed in part for septic patients especially for the ICU patient (for example, Acute Physiology and Chronic Health Evaluation, APACHE II; Sequential Organ Failure Assessment, SOFA), but also for the septic patient in the emergency department (ED) (Mortality in Emergency Department Sepsis, MEDS). The practicability of these scores in the ED is discussed Conclusions All three scores are useful prognostic factors for mortality and for ICU therapy in the ED, with usually lower patients’ severity of infection than in the ICU. The ICU-validated APACHE II and SOFA scores were of similar prognostic value as the ED-speciic MEDS score. P252 Validation of the new proposed Emergency Trauma Score (EMTRAS) M Mangini1, S Di Valvasone2, C Greco2, A Ognibene1, G Cappuccini1, R Spina1, R Tartaglia3, G Zagli1, A Peris1 1 Careggi Teaching Hospital, Florence, Italy; 2Postgraduate School of Anesthesia and Intensive Care, University of Florence, Italy; 3Centre for Clinical Risk Management and Patient Safety of Tuscany Region, Florence, Italy Critical Care 2010, 14(Suppl 1):P252 (doi: 10.1186/cc8484) Introduction Recently, Raum and colleagues [1] generated and validated a new trauma score (Emergency Trauma Score, EMTRAS) based on age, prehospital GCS, prothrombin time and base excess. Each parameter is subdivided into four classes, scored from 0 to 3 points. Scores of each class are summed to obtain the EMTRAS, ranging from 0 to 12. Here we present preliminary results of a study with the aim to validate this new scoring system and to compare it with other commonly used illness scores. Methods One hundred and ifty trauma patients admitted to the regional referral trauma center (Careggi Teaching Hospital, Florence, Italy) were studied. Predictive value of the EMTRAS score was compared with the Injury Severity Score (ISS), Revised Trauma Score (RTS), Trauma Injury Table 1 (abstract P252). Area under the curve (AUC) for EMTRAS and other scoring systems Variable AUC 95% CI EMTRAS 0.809 0.74 to 0.87 ISS 0.758 0.68 to 0.83 RTS 0.818 0.74 to 0.88 TRISS 0.909 0.84 to 0.96 SAPS II 0.845 0.78 to 0.90 Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S87 Severity Score (TRISS) and Simpliied Acute Physiology Score (SAPS) II. Logistic regression analysis was performed with MedCalc version 10 (MedCalc Software, Mariakerke, Belgium). Results The areas under the curves conirmed a good reliability of the EMTRAS score if compared with other validated trauma scores and with nontrauma-speciic scores such as SAPS II (Table 1). In particular, patients with EMTRAS scores of 5, 6 and 7 had a more major risk of death (odds ratio) of 2.3, 4 and 16, respectively, than patients with EMTRAS score below 5. Conclusions Our preliminary results conirm that EMTRAS has a good correlation with mortality risk. All four parameters of the score are simply available in a small amount of time, allowing physicians to quickly estimate trauma patients’ severity, before other examinations like CT scan are performed. Reference 1. Raum MR, et al.: Crit Care Med 2009, 37:1972-1977. P253 A new severity score for community-acquired pneumonia: PARB score N Uchiyama, R Suda, S Yamao, Y Tomishima, T Jinta, N Nishimura, N Chohnabayashi St Luke’s International Hospital, Tokyo, Japan Critical Care 2010, 14(Suppl 1):P253 (doi: 10.1186/cc8485) Introduction Community-acquired pneumonia (CAP) is one of the most common diseases encountered in the emergency department (ED). For the ED physician, it is quite diicult to estimate the severity of CAP patients in the ED because most CAP patients present at an earlier stage of disease. Although several societies such as ATS, IDSA and BTS have established severity scores for CAP, those scores are too complicated to calculate easily, especially in a busy department such as the ED. Therefore, a new simple and useful severity score for CAP is necessary for ED physicians. The purpose of our study is to develop a new severity score for CAP using 30-day mortality or patients needing more than 2 weeks oxygen therapy as the main outcomes. Methods We derived a prediction rule for outcomes by analyzing data on 243 adult inpatients with CAP between March 2006 and November 2008 in our hospital. Patients’ charts were abstracted to collect data relating to demographics, history, coexisting illnesses, laboratory results, and radiographic indings. Signiicant predictors of outcomes were identiied through logistic regression analyses. Results The following were independently associated with outcomes: presence of pleural efusions (P) (OR 5.0 (95% CI: 1.70 to 14.85)); albumin (A), <3.0 g/dl (OR 8.7 (1.43 to 53.29)); respiratory rate (R), >30/minute (OR 8.0 (1.62 to 39.64)); BUN (B), >25 mg/dl (OR 3.4 (1.07 to 11.07)). Patients were assigned according to whether they had these factors or not from class 0 to class IV (class 0 means the CAP patient had no these factors, class IV means the CAP patient had all these factors). Patients in risk class 0 to IV had a predicted probability of death or >2 weeks oxygen therapy of 0.03%, 0.08%, 52.2%, 75.0% and 100%, respectively. The sensitivity and speciicity of this model were 36.0% and 99.0%, respectively. Accuracy of this model was 91.9%. The area under the ROC curve was 0.8705. Conclusions The PARB score can accurately predict patients with CAP who are at risk for death or who will need more than 2 weeks oxygen therapy. This score may help ED physicians provide adequate treatment for patients with CAP. References 1. Fine MJ, et al.: N Engl J Med 1997, 336:243-250. 2. Lim WS, et al.: Thorax 2003, 58:377-382. P254 Modiied Early Warning Score and identiication of patients with severe sepsis L Zavatti, E Barbieri, E Amateis, M Girardis Azienda Ospedaliera-Universitaria Policlinico di Modena, Italy Critical Care 2010, 14(Suppl 1):P254 (doi: 10.1186/cc8486) Introduction The early identiication of patients with severe sepsis is a key point to provide the correct treatment and is actually based on clinical evaluation. In hospital wards, the Modiied Early Warning Score has been proposed as a system to identify early signs of deterioration and for outreach team activation. However, MEWS sensibility in early recognition of septic patients is still unknown. The aim of this study was to evaluate whether MEWS ≥4 is an adequate threshold for early identiication of patients with severe sepsis. Methods In 51 patients with severe sepsis (no septic shock) evaluated by our sepsis team, between November 2007 and December 2008 in the emergency department and no ICU wards, we collected the SOFA score and MEWS at the time of irst evaluation, the ICU admission rate and the 30-day mortality rate. We subdivided and compared patients into two groups on the basis of a MEWS value ≥4. Results In the 22 (43%) patients with a MEWS value ≥4, the SOFA score (5.9 ± 2.9) was similar to that measured in the 29 (57%) patients with MEWS value <4 (5.24 ± 2.6) whereas the ICU admission rate was larger (54%) than in patients with MEWS value <4 (24%) (P = 0.03). In patients with MEWS value ≥4 the 30-day mortality rate was slightly lower (15%) than in patients with MEWS value <4 (24%) (P >0.05). Conclusions The above data indicate that a MEWS value ≥4 has a very low sensitivity (43%) for identiication of patients with severe sepsis and therefore it should be used with caution for this aim and also as a criterion for ICU admission of septic patients (7/19 of patients admitted to the ICU with a MEWS value <4; sensitivity 63%, speciicity 68%). Reference 1. Subbe CP, Kruger M, Rutherford P, Gemmel L: Validation of a Modiied Early Warning Score in medical admission. QJM 2001, 94:521-526. P255 Impact of a systematic MEWS introduction on preoperative and postoperative evaluation in urgent/emergency surgery N Maccarone1, I Guerri1, M Franchi1, C Fricelli1, L Perretta2, G Zagli2, R Spina2, M Linden2, M Bonizzoli2, A Peris2 1 Postgraduate School of Anesthesia and Intensive Care, University of Florence, Italy; 2Careggi Teaching Hospital, Florence, Italy Critical Care 2010, 14(Suppl 1):P255 (doi: 10.1186/cc8487) Introduction The Modiied Early Warning Score (MEWS) has been used in medical wards as a decision-making instrument. Here we show a pilot study on MEWS introduction as a routine method for care improvement in urgency/emergency surgical patients. Methods Patients enrolled underwent urgent/emergency surgery due to trauma, appendicitis, cholecystitis, gut perforation or ischemia. Data collection with MEWS involved patients admitted for between April and October 2009. It was measured during preoperative evaluation and within 24 hours after surgery. To evaluate the role of MEWS utilization we use as outcome criteria: hospital length of stay (LOS), mortality, ICU or subintensive care unit (SCU) need. The MEWS group was compared with a control historical group (January 2008 to March 2009). Results Groups were similar in surgical diagnosis and demographic characteristics. Patients of the control group showed a higher mortality rate compared with the MEWS group (6.7 vs 3.7). The number of SCU admissions after surgery passed from 9.6% to 15.4% after MEWS Table 1 (abstract P255) Number Age, years (mean) ASA (mean) Hospital LOS, days (mean) Mortality, % (n) ICU admission, % (n) SCU admission, % (n) Control group 714 54.8 1.9 9.6 6.7% (48) 9.6% (69) 12.9% (92) MEWS group 432 53.9 1.9 8.75 4.4% (19) 14.8% (64) 10.2% (44) Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 introduction, whereas need for an ICU bed decreased from 12.9% to 10.6% (Table 1). Linear regression between high MEWS score and hospital LOS resulted signiicant (P <0.001). Conclusions These preliminary results indicate that MEWS, used in preoperative evaluation and follow-up in urgent/emergency surgical patients, can have an important impact on patient care and mortality. References 1. 2. 3. Cei M, et al.: Int J Clin Pract 2009, 63:591-595. Gardner-Thorpe J, et al.: Ann R Coll Surg Engl 2006, 88:571-575. Subbe CP, et al.: QJM 2001, 94:521-526. P256 Clinical predictors of physiological deterioration M Shehata, A Hussein, A Farouk, H Khaled Nagi Cairo University, Cairo, Egypt Critical Care 2010, 14(Suppl 1):P256 (doi: 10.1186/cc8488) Introduction To study the ability and the feasibility of the Modiied Early Warning Score (MEWS) as a screening tool to predict the high-risk critically ill patients who may develop cardiorespiratory arrest, and to compare between the MEWS and the Simpliied Acute Physiology Score II (SAPS II) regarding the sensitivity, speciicity and more easy to be applied. Methods Randomized, prospective study in the critical care medicine department in the Cairo University Hospitals including 100 critically ill patients newly admitted to the ICU. The MEWS is calculated daily during the period of the stay in the ICU with determination of the score Max, and SAPS II is calculated during the irst 24 hours. Results The MEWS score max grade of 8 or more was associated with the highest rate of arrest at which the sensitivity was 78.9%, speciicity was 93.5%, eicacy was 88.00%, with area under the curve (AUC) = 0.928. The SAPS II – Expanded grade of 50 or more was associated with the highest rate of arrest at which the sensitivity was 71.1%, speciicity was 100%, eicacy was 89.00%, with AUC = 0.872. Comparing the MEWS and SAPS II reveals that the MEWS has more sensitivity but less speciicity than SAPS II and eicacy is almost the same. Regarding the simplicity and applicability: MEWS is easier, faster and simpler. Conclusions The MEWS score is a useful screening tool to predict the high-risk patients who have high probability to develop cardiorespiratory arrest among the critically ill patients in the ICU. It is simple and practical, has more sensitivity than SAPS II and therefore should be recommended in clinical practice. Reference 1. Le Gall et al.: Crit Care 2005, 9:R645-R652. P257 Modiied Early Warning Scores: inaccurate summation or inaccurate assignment of score? M Edwards1, H McKay2, C Van Leuvan2, I Mitchell2 1 Australian National University, Canberra, Australia; 2The Canberra Hospital, Garran, Australia Critical Care 2010, 14(Suppl 1):P257 (doi: 10.1186/cc8489) Introduction Modiied Early Warning Scores (MEWS) have been utilised to improve the recognition and medical response to patient deterioration. Their usefulness is, in part, dependent upon their accuracy and to date only small datasets have been analysed to determine the accuracy of MEWS [1]. The aim of our study was to determine the accuracy of MEWS and the reasons for any inaccuracies found in a large dataset. Methods A prospective observational study of 9,672 vital sign sets and MEWS recordings in 315 adult medical and surgical patients admitted to four wards in both a tertiary and a metropolitan hospital over a 4-month period. Individual vital sign MEWS and total MEWS was assessed for accuracy against a computer-generated individual vital sign MEWS and total MEWS using the vital sign dataset and a modiied MEWS algorithm. Results Of the 9,672 total MEWS recorded, 3,504 (3,504/9,672, 36%) had discrepancies between the nurse-recorded and computer-generated total MEWS. Of these, 3,029 (3,029/3,504, 86%) underestimated the computergenerated total MEWS. In the majority of the total MEWS inaccuracies (2,443/3,504, 69.7%), the summation of the total MEWS from the individual MEWS was correct but the individual vital sign MEWS assignment S88 was inaccurate. In 711 (711/3,504, 20.3%) cases the individual vital sign MEWS assignment was correct but the summation for a total MEWS was incorrect, and in 350 (350/3,504, 10%) cases both the individual vital sign MEWS assignment and summation for a total MEWS was incorrect. Conclusions The underscoring between nurse-recorded and computergenerated MEWS indicates that the paper-based MEWS system is less likely to trigger a timely medical review and appropriate treatment of a deteriorating patient. Further education and regular auditing on the assignment of the individual vital sign MEWS may improve the accuracy of the score given that the summation of the score was not the predominant issue. Equally, an electronic system to calculate and summate the individual vital sign MEWS may reduce the total MEWS error. Reference 1. Prytherch DR, et al.: Resuscitation 2006, 70:173-178. P258 Analysis of Modiied Early Warning System scores and intraoperative factors on the incidence of sepsis and septic shock after elective major surgery PA Hampshire, A Guha, A Strong, D Parsons, P Rowan Royal Liverpool and Broadgreen University Hospital, Liverpool, UK Critical Care 2010, 14(Suppl 1):P258 (doi: 10.1186/cc8490) Introduction Severe sepsis is an important cause of morbidity and mortality following major surgery. Factors that are associated with an increased risk of sepsis following surgery include emergency surgery, patient co-morbidities, allogeneic blood transfusion and degree of surgical insult [1]. Physiological track-and-trigger systems are widely used to identify deteriorating patients. The Modiied Early Warning System (MEWS) is one such system, but has not been studied in regard to predicting the development of sepsis after surgery. Although high MEWS scores are associated with increased hospital mortality, the sensitivity of MEWS and other physiological track and trigger scores for predicting death or admission to intensive care is low [2]. Methods We carried out a prospective cohort study on 101 patients undergoing elective major surgery in a large university teaching hospital. The patients were followed up for 10 days, and the incidence of sepsis and septic shock was documented. MEWS scores were recorded daily for each patient. Admissions to critical care were documented, along with critical care length of stay. Results Twenty-seven (27%) patients developed sepsis and nine (9%) developed septic shock. Factors associated with the development of sepsis were intraoperative blood transfusion (P = 0.013), duration of operation (P = 0.004) and a postoperative MEWS score greater than 3 (P = 0.0003). Using multivariate logistic regression analysis, a MEWS score greater than 3 after surgery was the only factor that remained signiicantly associated with sepsis (odds ratio 4.89, P = 0.003). Although a high MEWS score was associated with sepsis after surgery, only ive (19%) patients who developed sepsis had an abnormal MEWS score prior to (mean 4.6 days) sepsis being diagnosed. Conclusions The routine use of MEWS scores in postoperative elective surgical patients may help to identify those patients at risk of developing sepsis. References 1. 2. Veltkamp SC, Kemmeren JM, Graaf YVD, Edlinger M, Werken CVD: Prediction of serious complications in patients admitted to a surgical ward. Br J Surg 2002, 89:94-102. Gao H, McDonnell A, Harrison DA, et al.: Systematic review and evaluation of physiological track and trigger warning systems for identifying at-risk patients on the ward. Intensive Care Med 2007, 33:667-679. P259 Temporal variability of medical emergency team calls J Tourtier, E Fontaine, J Vandenbossche, S De Rudnicki, E Falzone, M Borne, Y Auroy Hopital Val-de-Grâce, Paris, France Critical Care 2010, 14(Suppl 1):P259 (doi: 10.1186/cc8491) Introduction We evaluated temporal variability of telephone calls to the medical emergency team (MET), as well as patient outcome. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S89 or a diference in the pre-MET ward management in our hospital. Whilst inpatient mortality was high, patients who died were mostly managed without transfer to the ICU and the non-NFR death rate was low. This is consistent with a signiicant overlap between MET and end-of-life care. Alternatively the high mortality could relect that MET as an intervention occurs too late in these patients to favourably afect outcomes. A more detailed understanding of patients dying after MET calls is required to determine the best ongoing strategy to manage this high-risk group of patients. Figure 1 (abstract P259). Occurrence of calls throughout the day. Methods All calls over a 48-month period between December 2005 and November 2009 were included. The time of telephone calls was noted, and occurrence throughout the day was studied. We compared the number of calls between 8:00 and 20:00 and between 20:00 and 8:00, using a Wilcoxon test. Patient’s age, gender, reason for call, and outcome were entered into the ICU’s database. Results In the 4-year period, there were 136 calls, amongst which 17 were erroneous (12.5%). Figure 1 shows the occurrence of calls throughout the day. Between 8:00 and 20:00 and between 20:00 and 8:00, there were respectively 93 and 43 calls (P = 0.02). The immediate causes of intervention were cardiac arrest in 35%, respiratory depression in 8%, and decreased level of consciousness in 43% of cases (other: 14%). Eighteen percent of patients died during MET intervention. Amongst survivors, 31% were transferred in the ICU. Involved patients’ age was 67 ± 17 (male: 53%). Conclusions Reporting data might have less accuracy during nights. Nevertheless, despite diiculty of capturing such data, our series suggests that there is a temporal variability of medical emergency team calls. The fact that the majority of calls occurred between 8:00 and 20:00 may probably be a relection of the level of supervision and the general amount of patient activity within the hospital during the day. P260 Medical emergency team use and outcomes in an Australian private hospital J Barrett, J Reeves, T Bucknall, M Levinson Cabrini Hospital, Melbourne, Victoria, Australia Critical Care 2010, 14(Suppl 1):P260 (doi: 10.1186/cc8492) Introduction Medical emergency teams (METs) are widespread in Australian public hospitals and are becoming more common in private hospitals. The epidemiology of MET calls and patient outcomes post MET have not been well studied in the private hospital setting. Methods Prospective observational study of all inpatient MET calls in a 510-bed private teaching hospital for a 9-month period ending in August 2009. Information was collected on a standard data form after each MET call. Admission, discharge and mortality data were obtained from the hospital administrative database. Results There were 302 MET calls and 17,419 admissions with a MET call rate of 1.7% of admissions. Mean (SD) age was 72.9 (17.0) and 42.9% of patients were male. The rate of Code Blue calls was 0.26% and of unexpected (non-NFR) deaths 0.09% of admissions. The MET call rate was higher for medical than surgical patients (2.4% vs 1.1%, P <0.005). Inpatient mortality was 24.8% and patients receiving a MET call had an increased mean length of stay compared with the hospital average (16.1 vs 5.4 days, P <0.005). Activation of MET calls was delayed by more than 15 minutes in 7.6% of calls. Of the patients who died, only 16/69 (23%) were transferred to the ICU post MET call. Median (range) time from MET call to death was 1.8 (0 to 76.6) days. Conclusions The MET rate in our hospital overall is consistent with a maturing MET system. The higher MET rate in medical vs surgical patients is unexpected compared with the published experience in Australian public hospitals. This may relect a diference in the patient population P261 Continuously improving patient safety by a rapid response system V Van Bruggen, P Barendrecht, A Geense, E Van Dijk, M Achilleos, I Saris, M Meijer, A Deijkers, G Verwoerd, M Taks, E Oskam, R So Albert Schweitzer Hospital, Dordrecht, the Netherlands Critical Care 2010, 14(Suppl 1):P261 (doi: 10.1186/cc8493) Introduction Resulting from the Dutch VMS Safety Program ‘Prevent injury, work safely’, we recently started to implement a rapid response system (RRS) in our hospital. The RRS consists of: a warning signs pocket card, a Rapid Response Team (RRT) and an evaluation system. The purpose of the RRS is to recognize and treat the patients with clinical warning signs early on the ward to reduce preventable hospital-wide avoidable injury. We present the irst results of the implementation of the RRS. Methods Data regarding the RRT calls and the evaluations were collected from 1 May 2008 until 30 April 2009 (total: 114 calls). We were interested in: the cause of the RRT call, the results of the call and the advice following the evaluation of the calls. Results The main reasons for the calls were respiratory failure (47%), hemodynamic problems (31%), neurological problems (7%) or a combination of problems in 15%. In 45% of the calls the patient was admitted to the ICU, medium care unit (MCU) or cardiac care unit (CCU). In 55% of the calls the patient stayed on the ward. During the call 14% of the patients who stayed on the ward obtained a do-not-resuscitate or a do-not-transfer-to-the-ICU order. These decisions were always taken in close cooperation with the doctor taking care of the patient on the ward. Evaluations were performed in 76% of the calls. In 45% of the calls the warning signs were recognized in time. Problems identiied were late identiication of clinical deterioration of the patient (30%) and failure to treat to a patient with clinical warning signs due to failures in planning (6%) or communication (26%). Conclusions In 45% of the RRT calls, transfer of the patient to the ICU/MCU/ CCU is required. Hospital-wide improvement initiatives should focus on: timely recognition of clinical deterioration of the patient; failures in planning and communication; and timely agreed restrictive measurements on the ward. P262 Role of critical care outreach to provide the intention to treat of hematological disorders: a pilot study I Guerri1, C Greco1, L Perretta2, G Cianfaldoni2, G Longo2, S Batacchi2, R Spina2, A Bosi2, G Zagli2, A Peris2 1 Postgraduate School of Anesthesia and Intensive Care, University of Florence, Italy; 2Careggi Teaching Hospital, Florence, Italy Critical Care 2010, 14(Suppl 1):P262 (doi: 10.1186/cc8494) Introduction Hematological malignancy patients admitted to the ICU due to complications are at high risk of death. In the second half of 2008 we started Critical Care Outreach (CCO) activity. The purpose of this team was to start intensive care early as possible for avoiding mechanical ventilation and multiorgan failure for improving intensive treatment outcome. Methods One hundred and twenty-six hematological patients from 2003 to November 2009 were included in the study. We divided patients into three groups: (1) pre-CCO group: 56 patients from 2003 to 31 December 2007; (2) transition group (2008): 22 patients admitted to the ICU and three treated in the hematology ward; (3) post-CCO group (January to November 2009): 18 patients admitted to the ICU and 27 patients treated in the haematology ward. In the post-CCO group 10 of the 27 patients were admitted to the ICU and 17 of these were treated in hematology ward, and nine of these received NIV (Figure 1). We deined six criteria for activation of the CCO team: radiological signs of pneumonia, organ Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S90 wards. The Score 2 Door time is a pragmatic tool to quantify and benchmark these delays in order to identify obstacles to patient low and improve care. References 1. 2. McQuillan P, et al.: Br Med J 1998, 316:1853-1858. Subbe CP, et al.: QJM 2001, 94:521-526. P264 A comparison of injected lidocaine 2% and no analgesia for peripheral intravenous cannula insertion in the emergency department G Papakitsos1, T Papakitsou2, A Kapsali1 1 General Hospital Arta, Greece; 2General Hospital Messologi, Greece Critical Care 2010, 14(Suppl 1):P264 (doi: 10.1186/cc8496) Figure 1 (abstract P262). failure, positive microbiological test, need for increase in oxygen therapy, SIRS progression, and Modiied Early Warning Score (MEWS) >3 [1]. Primary outcome is the ability of the CCO to provide the intention to treat hematological malignancies. Results After CCO introduction, intention to treat was guaranteed at 90% in 2008 and at 41% in 2009. Comparing the number of criteria of activation, during 2008 and 2009 intensivists were activated earlier, with a lower number of criteria. The ICU mortality rate passed from 60% in 2003 to 54.5% in 2008 and 33.3% in 2009. Also the need for mechanical ventilation decreased after CCO introduction. Conclusions The introduction of CCO and activation criteria improves the intention to treat and reduces ICU admissions and mortality. Reference 1. Subbe CP, Kruger M, Rutherford P, Gemmel L: QJM 2001, 94:521-526. P263 Score to door time: a benchmarking tool for rapid response systems C Subbe1, L Durham2, J Welch3, K Oglesby1 1 Wrexham Maelor Hospital, Wrexham, UK; 2NorthTyneside General Hospital, North Shields, UK; 3University College Hospital, London, UK Critical Care 2010, 14(Suppl 1):P263 (doi: 10.1186/cc8495) Introduction Delay in recognition and treatment of deteriorating patients is a signiicant contributor to mortality of emergency admissions to intensive care (ICU) [1]. Rapid response systems (RRS) seek to improve this process. Service evaluation of RRS might be hampered by the lack of comparative quality assurance tools. The aim of this international collaborative audit was to test a benchmarking tool for the process of emergency admissions to the ICU in analogy to the door-to-needle time in cardiology. Methods Data were collected in August and September 2009. Collaborators were asked to audit data from a minimum of ive emergency admissions to the ICU (range 3 to 35 admissions). The Score 2 Door time was deined as the time between irst trigger of the local track-and-trigger system and time of admission to intensive care. Collaborators were asked to give possible causes for delays in transfer to the ICU. Observations were risk-stratiied with an age-adjusted Modiied Early Warning Score (MEWS-A) [2]. Data were anonymised and hospitals were coded in a random fashion. Results Up to 22 September, data for 125 patients from 17 hospitals had been submitted. Of these, four were non-UK hospitals (US x 1, Denmark x 1, Australia x 2) using medical emergency team type of systems and UK hospitals used a summary score. Median age was 67 years. Mean APACHE II score on admission to the ICU was 18 (SD 8). The median Score 2 Door time was 3:15 (range 0:09 to 19:45). Median time was shorter in the four non-UK hospitals (1:29 vs 4:05). Sicker patients (as evidenced by a higher MEWS-A trigger) did not have shorter Score 2 Door times. The main quoted causes for delays in ICU admission were transient improvement of condition (n = 4), immediate treatment on the ward (n = 9), a procedure (n = 12; that is, surgery, computer tomography), a shortage of intensive care beds at the time of referral (n = 11) or waiting for a senior review (n = 14). Conclusions Organisational and other delays in ICU admission might reduce the impact of RRS on care of deteriorating patients on general Introduction Many patients who present to the emergency department require placement of a peripheral intravenous line, which frequently causes pain and anxiety. We compare pain and anxiety associated with peripheral intravenous cannula insertion after pretreatment with no local anaesthesia or subcutaneously injected, bufered 2% lidocaine. Methods In a randomized study, peripheral intravenous cannulas were inserted in 185 patients arriving in the emergency department. In random order, insertion sites were pretreated with nothing or injected, bufered lidocaine. After each intravenous insertion, subjects recorded pain, anxiety, and preference (as patient and provider) for each technique on a 10-point numeric rating scale. Higher scores indicated greater pain, anxiety and preference. Results Median pain scores were 7 (5 to 8) without local anaesthesia and 1 (1 to 2) with injected, bufered lidocaine. Median anxiety scores were 4 (3 to 7) without local anaesthesia and 2 (1 to 3) with injected, bufered lidocaine. Most intravenous placement attempts were successful, regardless of technique. Eighty-seven per cent of subjects indicated they would always request bufered lidocaine for peripheral intravenous insertion. In the emergency department or other busy practice setting, injected, bufered lidocaine has the advantage of being immediately efective. Conclusions Pain and anxiety associated with peripheral intravenous insertion is signiicantly reduced by using topical injected, bufered lidocaine. Injected, bufered lidocaine reduces intravenous insertion pain more than pretreatment with no local anaesthesia, without afecting success. Reference 1. McNaughton C, et al.: A randomized, crossover comparison of injected bufered lidocaine, lidocaine cream, and no analgesia for peripheral intravenous cannula insertion. Ann Emerg Med 2009,54:214-220. P265 High-sensitive troponin T measurement for patients with acute chest pain: improvement of diagnostics? S Popp, S Herdtle, H Pohlmann, M Poravas, D Umarov, R Bach, T Bertsch, M Christ Klinikum Nueremberg, Germany Critical Care 2010, 14(Suppl 1):P265 (doi: 10.1186/cc8497) Introduction Highly precise laboratory methods have been developed to determine cardiac troponin levels (cTn) according to the universal deinition of acute myocardial infarction (MI). We examined the impact of lowering the level of detection of cTn measurement in consecutive patients presenting to the emergency department (ED) of a large German community hospital. Methods cTnT levels were measured using a standard assay (Roche cTnT fourth generation; cutof ≥0.04 ng/ml) and a high-sensitive assay (Roche cTnThs; cutof ≥0.014 ng/ml). Patients were categorized to have an acute MI according to the universal deinition using the old or the new cutof point of cTnT levels (cTnT ≥0.04 ng/ml or cTnThs ≥0.014 ng/ml). Results We analyzed 137 consecutive patients with chest pain admitted to the ED (age: 65.7 ± 15.5 years; 63.5% male; in-hospital mortality: 0.7%). Totals of 36%, 22% and 42% of patients presented within 2 hours, 2 to 6 hours and >6 hours of chest pain. Using the old cutof point, 30 patients have been classiied as acute MI (type 1 MI: 67%; type 2 MI: 33%). Using the new cutof point (TnThs ≥0.014 μg/l), diagnosis of acute MI signiicantly Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 increased by 116% (n = 65; type 1 MI: 54%; type 2 MI: 46%; P <0.05). Type 1 MI increased by 75%, which was relected by a 57% decrease of patients formerly classiied as instable angina. Of note, increases of MI diagnosis were mainly relected by a 200% increase of type 2 MI (for example, acute heart failure, tachycardia or hypertensive crisis). Numbers of patients with noncardiac chest pain were not signiicantly changed with the use of the new cutof point. AUC of admission cTnT levels were 0.76 and 0.96 for the cTnT fourth generation and cTnThs (P <0.05). At admission, sensitivity and speciicity of cTnThs were 93% and 94% for the detection of acute MI, while they were 32% and 96% using cTnT fourth generation. Conclusions Using lower cutof points for the deinition of MI as suggested by current recommendations, the rate of chest pain patients with acute MI doubled. Because the increased rate of patients categorized as acute MI is mainly relected MI type 2, the ED triage decision at lower cutof levels of cTnT levels should include patient history, physical examination, 12-lead ECG and cardiac imaging. P266 Abstract withdrawn P267 Correlation of lung comet score with decreased gas exchange in patients with acute pulmonary edema: a pilot study G Guiotto1, F Dello Vicario1, R Marino1, F Paladino1, S Scott2, F Schiraldi1 1 San Paolo Hospital, Napoli, Italy; 2Gold Coast Hospital, Southport, Australia Critical Care 2010, 14(Suppl 1):P267 (doi: 10.1186/cc8499) Introduction The aim of this study was to determine the correlation between B+ line score and blood gas analysis (BGA) parameters in patients with acute cardiogenic pulmonary edema (ACPE). The presence of B+ line artifacts on lung US is correlated with increased extravascular lung water. In patients with acute decompensated heart failure the resolution of B+ lines can be used to monitor resolution of pulmonary congestion. A simple nine-point comet score has been proposed to quantify B+ lines and monitor ACPE treatment [1]. Methods Twenty-one patients with ACPE were submitted to lung US and BGA on presentation at 2 and 24 hours after admission. Lung US was done in nine thoracic areas and scored one point if B+ lines were present. A score of 10 was given for the presence of multiple coalesced comets in all ields (white lung). BGA values were used to calculate PO2/FiO2 (P/F) and A–a gradient. Results A total of 64 scans were performed with simultaneous BGA. Ninety-eight percent of patients presenting with white lung were severely hypoxic (PO2 <50 mmHg; P/F <200). Figure 1 illustrates a strong linear correlation between reduction in comet score and improvement in P/F S91 (r = –0.73; P <0.001). A decrease in comet score of 2 points corresponded to a minimum increase of 20 points in P/F (P <0.05). The correlation between comet score and A–a gradient was less striking signiicant (r = –0.51; P = 0.05), perhaps because patients with underlying lung disease were not excluded from this pilot study. Conclusions There is a strong negative correlation between lung comet score and gas exchange in patients with ACPE. In these patients, serial thoracic US may reduce the need for repeated invasive BGA monitoring and further help tailor therapy. Reference 1. Volpicelli G, Caramello V, Cardinale L, et al.: Bedside ultrasound of the lung for the monitoring of acute decompensated heart failure. Am J Emerg Med 2008, 26:585-591. P268 Magnitude of irst medical contact in the long-term prognosis of patients treated with STEMI D Becker, G Barczi, G Szabo, A Horvath, B Merkely Semmelweis University, Budapest, Hungary Critical Care 2010, 14(Suppl 1):P268 (doi: 10.1186/cc8500) Introduction Numerous STEMI patients are treated successfully in the Central PCI on call system. Up until this time we do not have data about the irst medical contact’s – National Emergency Service or other medical staf – impact on long-term prognosis. It is also unknown how the method of transport to the PCI center (direct or secondary) inluences the prognosis. Our aim was to evaluate the magnitude of irst medical contact and the type of transport in the short-term and long-term prognosis. Methods We evaluated the 30-day and 1-year mortality data of 1,890 consecutive patients who were treated with primary PCI due to STEMI. We selected the patients according to the irst medical contact: National Ambulance Service or other medical staf, and according to the type of transport: direct or secondary transport. At the follow-up procedure we used the university’s and the National Health Insurance Found’s database. Results The 1,890 patients’ follow-up rate was 100%. First, 34.7% of the patients (656/1,890) called for Emergency Service directly. This rate was even lower in working hours (30.6% – 205/671). It was also observed that as the time delay was increasing from the onset of symptoms, the number of people who called for Emergency Service was lower. Between 10 and 12 hours it was just 12.2% (19/155). Thirty-day mortality (Ambulance Service versus other staf ): 7.3% (48/656) vs 9.5% (117/1232) – P = 0.1. One-year mortality: 12.7% (83/656) vs 16.1% (199/1232) – P = 0.04. Second, 44.4% of the patients (838/1,890) were transported directly to the PCI center (direct transport). Thirty-day mortality (direct versus secondary transport): 60/838 (7.2%) vs 105/1,052 (9.9%); 1-year mortality: 106/838 (12.6%) vs 176/1,052 (16.7%). The diference is signiicant at 30 days and at 1 year also. The 30-day mortality rate is higher with 24%, the 1-year mortality rate is higher with 15% among those patients who were admitted after a secondary transport. Conclusions The long-term prognosis is signiicantly better among those STEMI patients who are transported directly to the PCI center and where the irst medical contact is the National Ambulance Service. P269 Ultrasound-guided hematoma block and fracture reduction: a new way to go forward M Majeed, A Mukherjee, R Paw Russells Hall Hospital, Dudley, UK Critical Care 2010, 14(Suppl 1):P269 (doi: 10.1186/cc8501) Figure 1 (abstract P267). Correlation between reduction in comet score and improvement in P/F. Introduction The conventional treatment for most distal radial fractures is closed reduction and cast immobilization. Conventionally the hematoma block is used to reduce the fractures but it is done blindly and radiographic techniques have been essential and efective in monitoring these reductions [1]. Radiation-free ultrasonography, however, can provide both real-time and dynamic multiple-plane images with a small and simpleto-use transducer that can be operated with only one hand. We therefore wanted to see whether the real-time and dynamic multiple-plane Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 observation capabilities of ultrasonography would allow an ED physician to perform under direct vision a hematoma block and closed reduction without multiple attempts of either as are frequently required when only conventional techniques are used. Methods Sonographically guided hematoma block and closed reduction was performed in three patients in the emergency department for an acute distal radial fracture. The eicacy of this method was evaluated and compared with that of conventional techniques. Results The ultrasound images helped giving the hematoma block under direct vision and delineated the fractures as accurately as did the conventional radiographs. All parameters measured on the ultrasound images showed substantial restoration of anatomic alignment after reduction. Under direct vision, the hematoma block helped reduce the number of attempts and was less painful and achieved more patient satisfaction. Conclusions Sonography is an accurate, simple, time-saving, less painful and radiation-free tool. Reducing badly displaced or angulated forearm fractures in the emergency department can be diicult. Multiple attempts at reduction may be required, with repeated trips to the radiology department, before an adequate reduction is achieved [2]. Therefore ultrasound-guided hematoma block and reduction of diicult forearm fractures reduces the number of needle attempts and allows the physician to assess the adequacy of the reduction at the patient’s bedside. References 1. 2. Sonography for monitoring closed reduction of displaced extra-articular distal radial fractures. J Bone Joint Surg Am 2002, 84:194-203. Ultrasound guided reduction of pediatric forearm fractures in the ED. Am J Emerg Med 2000, 18:72-77. P270 Pulmonary edema in the prehospital setting: the importance of early treatment S Lourenco, J Figueira Coelho, A Martins Baptista Curry Cabral Hospital, Lisbon, Portugal Critical Care 2010, 14(Suppl 1):P270 (doi: 10.1186/cc8502) S92 P271 Eicacy of bedside ultrasonography in early diagnosis of patients admitted to the emergency department with dyspnea E Dogan, S Girisgin, D Dündar, B Cander Selcuk University Meram Faculty of Medicine, Konya, Turkey Critical Care 2010, 14(Suppl 1):P271 (doi: 10.1186/cc8503) Introduction We designed our study to ind a useful USG pattern for diagnosis and assessment of dyspnea. We also compared utilities of chest radiograms in a supine position, thorax CT and bedside USG techniques. Methods In Selcuk University Meram Medical Faculty, during the year 2009, 60 patients who had acute dyspnea were included in our study (30 patients with chest trauma and 30 patients with nontraumatic causes). We designed our study as prospective. We tried to determine pathologies that have positive and negative Sliding Lung Sign (SLS) in USG examinations. We also investigated its reliability in diferential diagnosis of acute dyspnea. Results First of all we performed chest radiograms on all patients in a supine position. After that we performed CT scans. All of the results were interpreted by a detached radiologist. Then we performed bedside thoracic USG to ind SLS by physicians in the ER. We conceded CT results as the golden standard and compared the results with chest radiograms and USG indings. The SPSS 13.0 program and Χ2 test were used for statistical analysis (P <0.05). According to our indings, SLS in USG examinations has a sensitivity of 84% and a speciicity of 97% with a 97% positive predictive value and 83% negative predictive value. Conclusions Throughout the years, USG examinations were deined as inappropriate in lung examinations but in our study we reached a conclusion that they are a necessity. Bedside sonographic examination allows impetuous diagnosis. But every respiratory failure has its own sonographic pattern so mistakes are inevitable. Nevertheless we believe that if profound studies like ours keep coming and if more and more clinicians begin to use USG examinations, the SLS diagnostic value will rise and become a routine element in the ER. References 1. 2. Introduction Patients with acute cardiogenic pulmonary edema require rapid assessment and therapy to prevent progression to respiratory failure and cardiovascular collapse. Lisbon city has emergency medical teams that respond to situations where the life of the patient is at risk and whose goal is to begin treatment if indicated and assure transport to the hospital in the best conditions possible. We studied the intervention of one of these teams on patients with acute pulmonary edema. Methods Medical records of the activity of our prehospital emergency vehicle from April 2005 to October 2009 were analyzed. All records of patients having a clinical diagnosis of acute pulmonary edema at the scene were considered. Incomplete records were excluded. Results In the 55 months considered our emergency vehicle attended 9,856 calls, from which 493 (5%) were for acute pulmonary edema. Patients ages range from 20 to 99 years, with a mean age of 75.8 years, and 47.8% were males. A total of 58.6% of calls were made on the night period (from 8 pm to 8 am), most between 8 pm and 0 pm. Risk factors included arterial hypertension (62.3%), ischemic heart disease (43.2%), diabetes mellitus (31.8%), heart failure (23.3%), atrial ibrillation (13.2%) and renal failure (9.9%). On arrival of the prehospital medical team at the scene, 24 patients (4.9%) required immediate intubation and ive evolved to cardiac arrest, four of whom were successfully resuscitated and transported to hospital. Conclusions Our prehospital medical teams attended a large number of patients with pulmonary edema during this period. We recorded a small number of patients requiring mechanical intubation and a high rate of survival on those sufering from cardiac arrest in this context. We believe this is largely because of the decreased response time that prehospital emergency ofers in this situation, allowing the institution of early treatment. References 1. 2. Dickstein K, et al.: ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the diagnosis and treatment of acute and chronic heart failure 2008 of the European Society of Cardiology. Eur J Heart Fail 2008, 10:933-989. Tresch DD, et al.: Out-of-hospital pulmonary edema: diagnosis and treatment. Ann Emerg Med 1983, 12:533-537. 3. Razzaq QM: Use of the ‘sliding lung sign’ in emergency bedside ultrasound. Eur J Emerg Med 2008, 15:238-241. Blaivas M, Lyon M, Duggal S: A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. Acad Emerg Med 2005, 12:844-849. Wüstner A, Gehmacher O, Hämmerle S, Schenkenbach C, Häfele H, Mathis G: Ultraschalldiagnostik beim stumpfen Thoraxtrauma. Ultraschall Med 2005, 26:285-290. P272 Auscultation in light: comparison of ampliied and traditional stethoscopes J Tourtier, S Coste, E Fontaine, N Libert, M Viaggi, E Forsans, M Borne Hopital Val-de-Grâce, Paris, France Critical Care 2010, 14(Suppl 1):P272 (doi: 10.1186/cc8504) Introduction Many air medical transport programs use pulse oximeters, end-tidal carbon dioxide monitors and other devices as indirect measures of respiratory and cardiac status. Thus, these methods do not replace cardiac auscultation during light, which may be needed to identify sudden critical change. And the ability to compare left-sided and right-sided breath sounds may be essential to conirm the appropriate placement of endotracheal tubes as well as to diagnose pneumothorax. The ability for auscultation during air medical transport is compromised by high ambient noise levels. The aim of this study was to assess the capabilities of a traditional and an ampliied stethoscope (which is expected to reduce background and ambient noise) to assess heart and breath sounds during medical transport in a FALCON 50 plane. Methods A prospective, double-blind, randomized study was performed. We tested one model of traditional stethoscope (Littman® cardiology III) and one model of ampliied stethoscope (Littman 3100). The sound level was ampliied in six of the eight increments of the ampliied stethoscope. Practitioners on board were all experienced in air medical transport. They had normal audiologic testing. We studied 18 heart and lung auscultations, during real medical evacuations on board the Falcon 50 (medically conigured; Dassault aviation). For each, the quality of Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 auscultation was described using a numeric rating scale (ranging from 0 to 10, 0 corresponding to ‘I hear nothing’, 10 to ‘I hear perfectly’). Comparisons were accomplished using a t test for paired values. Results Age of patients was 42 ± 11 years, 78% were males. The body mass index was 29.5 ± 4.7. For cardiac auscultation, the value of the rating scale was 5.7 ± 1.4 and 6.5 ± 1.8, respectively, for the traditional and ampliied stethoscope (P = 0.027). For lung sounds, quality of auscultation was estimated at 3.6 ± 2.3 for the traditional stethoscope, at 3.9 ± 2.9 for the ampliied stethoscope (P = 0.193). Conclusions We concluded that light practitioners in the Falcon 50 are more able to hear cardiac sounds with an ampliied than with a traditional stethoscope, whereas there is no signiicant diference concerning breath sound auscultation. These indings suggested to the investigators that Falcon 50 noise and human breath sounds might share a common or substantially overlapping frequency spectrum, with ampliication of one necessarily amplifying the other. To assess this hypothesis, further studies are needed to evaluate the sound frequency spectrum in the medically conigured Falcon 50. P273 Performance of ventilators at simulated altitude: study of fraction of inspired oxygen J Tourtier, S Ramsang, E Forsans, S De Rudnicki, A Chrissment, J Schaal, M Borne Hopital Val-de-Grâce, Paris, France Critical Care 2010, 14(Suppl 1):P273 (doi: 10.1186/cc8505) Introduction We studied the performance of two respirators employing an advanced turbine delivery system: LTV 1000, Tbird VSO2. We assessed the ability of the ventilators to deliver to a normal lung model a set fraction of inspired oxygen (FiO2) at diferent simulated cabin altitudes. Methods We used a decompression chamber to mimic the hypobaric environment at a range of simulated cabin altitudes of 1,500, 2,000 and 3,000 meters (4,000, 5,333, 8,000 feet). A model of normal lung was used. Concerning the Tbird VSO2, cabin altitude was input. Ventilators were tested with FiO2 set at 50% and Vt set at 700 ml. We noted the efective FiO2 assessed by the ventilators (paramagnetic analysis). We measured the FiO2 really delivered with a dedicated instrument of the French physiological laboratory of aviation and space medicine of the Air Force. Comparisons of preset and assessed FiO2 to actual measured FiO2 were accomplished using a t test for each altitude. Results Figure 1 shows the data with FiO2 set at 50%. Conclusions On one hand, both ventilators showed a moderate variation between FiO2 set and delivered. On the other hand, variations between FiO2 delivered and assessed are high, suggesting ineicacity of ventilators’ paramagnetic analysis in hypobaric conditions. Figure (abstract P273). S93 P274 Aeromedical evacuation of the French Army: survey of the past 10 years S Coste, J Tourtier, C Daudé, M Viaggi, E Morgand, M Borne Hopital Val-de-Grâce, Paris, France Critical Care 2010, 14(Suppl 1):P274 (doi: 10.1186/cc8506) Introduction The Military Medical Service of the French Forces insures the support of 29,000 French servicemen spread around the world each year and performs as such their medical evacuation by air towards France to guarantee their adequate treatment as soon as possible. This knowledge is sometimes also used for a national civilian abroad. We propose to describe the epidemiology of medical evacuation (MEDEVAC) made in the past 10 years. Methods We analysed data for every patient evacuated since 1 January 2000 and noted the destination, the number of patients per light, the age, the gender, the status (military or civilian), the pathology, the presence of a specialist in the medical team (intensivist, cardiologist, psychiatrist) and the recipient hospital. The presence of an intubated ventilated patient or transfusion in light was studied. Results A total of 420 strategic MEDEVACs were carried out in 10 years (per year: 42 ± 6.9) in favor of 529 patients, among whom 90% were French servicemen. Each light carried between one and 15 patients. Europe represents 42% of the original location of evacuation, Africa 39% and the Middle East 17%. An anesthetist–resuscitator reinforced the medical team in 51.7% of the evacuations. The patients with respiratory assistance are present in 19.8% of the lights and transfusion occurred in 3.1% of the lights. Traumatic pathology is predominant (49.5% of patients), divided into three major causes nearly equally: road traic accident, ballistic and others. Burns represent a signiicant proportion (6.8%) of the causes of evacuation. Other causes are represented by 30.2% for medical conditions (n = 160 among which 59 cardiac afections), 10.2% for nontraumatic surgical afections and 2% for psychiatry. Finally 25.5% of the patients were accommodated in an ICU, 6% in a speciic center for treatment of burns, 35.3% in a service of surgery and 24.6% in medicine. Conclusions If the number of MEDEVACs is relatively stable over the past decade, destinations and causes are changing. Africa remains an usual location of evacuation, the part of Europe tends to decrease for the beneit of the Middle East, which became in 2009 the predominant destination (21/47) stretching out the duration of lights. The causes of evacuations testify to the intensity of the commitment of French forces through traumatic afections, and in particular of ballistic origin, which are in 2009 the main traumatic afections (15/31). The corollary is an increase of the appeal to the resuscitators to deal with trauma patients. P275 Comparison of two disaster drills’ management performed by trained and not-trained students: key times evaluation FL Barra, L Carenzo, PL Ingrassia, M Tengattini, F Prato, D Colombo, F Della Corte University of Eastern Piedmont ‘Amedeo Avogadro’, Novara, Italy Critical Care 2010, 14(Suppl 1):P275 (doi: 10.1186/cc8507) Introduction The aim of this report is to compare two disaster exercises’ management of students with diferent backgrounds. To our knowledge nobody has ever compared two exercises, probably because of the diiculty in their evaluation. We implemented a tool for an objective evaluation [1] and we used it for this purpose. Methods Both drills represented a ceiling collapse over a crowded room with a similar amount of casualties and similar severity index. The START triage system was used. The trained students (T) were attending the European Master in Disaster Medicine (EMDM), while the not-trained students (NT) were at the beginning of an introductory course in disaster medicine. During the exercises we recorded key victim–provider interaction times [2] using victim-based data collection. Each victim had their own data card to record triage and time information. Results In this preliminary report we present data regarding the scene length of stay (LOS) and triage to collecting area/advanced medical post time (T-AMP). The LOS was 67.5 (50.0 to 111.0) minutes (25 to 75 IQR) for T as compared with 145.0 (110.0 to 150.0) minutes (25 to 75 IQR) for NT Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 (P <0.001). Stratiication according to assigned triage code showed no diference for high-priority codes (reds and yellows) as opposed to the green code (55.0 (47.0 to 75.0) minutes for T vs 145.0 (141.0 to 155.0) minutes for NT with P <0.01). T-AMP was 10.0 (3.0 to 34.5) minutes for T as compared with 63.5 (19.5 to 104.3) minutes for NT (P <0.001). Stratiication according to triage code showed no diference for red codes between T and NT but showed a diference for yellow codes (36.5 (15.0 to 82.0) vs 71.0 (30.0 to 99.0) minutes) and green codes (7.0 (3.0 to 12.0) vs 85.0 (17.3 to 115.0) minutes) with P <0.01. Conclusions Both teams evacuated red codes before the yellow ones in similar time. T-AMP was shorter considering global, yellow and green codes for T as opposed to NT. Global and green LOS was also shorter in the T group as opposed to NT. Training seems to inluence global exercise management, less afecting red codes but with an impact on yellow and green evacuation strategies. References 1. 2. Ingrassia PL, et al.: Evaluation of medical management during a mass casualty incident exercise: an objective assessment tool to enhance direct observation. J Emerg Med 2009. [Epub ahead of print] Green GB, et al.: Generic evaluation methods for disaster drills in developing countries. Ann Emerg Med 2003, 41:689-699. P276 Acute severe asthma: performance of ventilator at simulated altitude J Tourtier, E Falzone, J Schaal, L Franck, G Edjo Nkilly, A Chrisment, M Borne Military Hospital Val-de-Grâce, Paris, France Critical Care 2010, 14(Suppl 1):P276 (doi: 10.1186/cc8508) Introduction Exacerbation of asthma can appear during air transport. Severe patients, not responding to conventional therapy can require ventilator support. We evaluated the performance of two transport ventilators, built with turbine technology – the T-bird VSO2 and the LTV 1000 – for use during aeromedical evacuation of acute severe asthma. We have assessed the ability of both ventilators to deliver to an acute severe asthma model a tidal volume (Vt) set at diferent simulated altitudes, by changing the ambient air pressure. Methods We used a decompression chamber to mimic the hypobaric environment at a range of simulated cabin altitudes of 1,500, 2,500 and 3,000 meters (4,000, 6,670, 8,000 feet). Ventilators were tested with realistic parameters. Vt was set at 700 ml and 400 ml in an acute severe asthma lung model. The protocol included three measurements for each simulated altitude. Comparisons of preset to actual measured values were accomplished using a t test for each altitude. Results Figure 1 summarizes the data. With altitude, the T-bird VSO2 showed a decrease in volume delivered. Comparisons of actual delivered Vt and set Vt demonstrated a signiicant diference starting at 1,500 m for a Vt set of 700 ml, at 2,500 m for Vt set of 400 ml, with a negative variation of more than 10% compared with tidal volume set at respectively 3,000 and 2,500 m. With decreasing barometric pressure, the LTV 1000 showed mostly an increase in volume delivered. Comparisons of actual delivered Vt and set Vt demonstrated a signiicant diference at 1,500 m for a Vt set of 700 ml, at 2,500 m for a V test of 400 ml. The delivered tidal volume remained within 10% of the set Vt. Figure 1 (abstract P276). Acute severe asthma, Vt delivered in altitude. S94 Conclusions The T-bird VSO2 progressively delivered lower volumes as barometric pressure decreased; whereas the LTV 1000 showed a moderate increase in volume delivered for the acute severe asthma lung model, with increasing altitude, but maintained the delivered volume within 10% of the set Vt up to 3,000 m. P277 Validation of a new French-language triage algorithm: the ELISA scale J Jobé1, A Ghuysen1, P Gérard2, G Hartstein1, V D’Orio1 1 University Hospital, Liège, Belgium; 2University of Liège, Belgium Critical Care 2010, 14(Suppl 1):P277 (doi: 10.1186/cc8509) Introduction For some time, most emergency departments have been experiencing severe overcrowding which could lead to reductions in the quality of care. Consequently, nurse triage tools have been developed with the aim of getting ‘the right patient to the right resources, at the right place and at the right time’. However, diferences in emergency medical services in diferent countries have limited the generalisation of preexisting triage systems; for this reason, speciic algorithms corresponding to local characteristics are needed. Accordingly, we developed a speciic French-language triage system called ELISA (Echelle Liegeoise d’Index de Sévérité à l’Admission – Liege admission severity scale). We aimed to test its validity in the present study. Methods The ELISA is a ive-category (U1 to U5) nursing triage algorithm, using low charts based on vital signs and anamnestic data. Each category is associated with a pre-established time delay for irst medical contact. We tested inter-rater and intra-rater agreement respectively. As concerns inter-rater agreement, nine triage nurses sorted the same 100 patients. The assigned classiications compared the reference assignment and were analyzed with Cohen’s kappa coeicient. Intra-rater agreement was tested by asking 30 triage nurses to sort the same 10 patients at two diferent times (T1 was early morning and T2 was late night). We compared the classiication at T1 and T2 with the null hypothesis being no diference and determined whether diferences were nurse dependent. Results Statistical analysis of intra-rater agreement revealed that the mean diference between classiication at T1 and T2 did not signiicantly depend on the nurse (P = 0.3487). This result allowed pooling of the data and testing to determine whether the mean was diferent from zero. We used the Sign test and found that classiication at T1 was not diferent from classiication at T2 (P = 0.581). As concerns inter-rater agreement, we used Cohen’s kappa coeicient, which revealed an almost perfect agreement between classiication by nurses and the reference. Conclusions The need for a speciic triage tool in our emergency department led us to develop a new French-language triage scale. The present study demonstrates that this scale is a valid triage tool with very good inter-rater and intra-rater agreement. Such results now allow a future study to evaluate its eiciency. P278 Examining the suitability of medical admissions to the emergency short stay ward of a large UK hospital E Hartley, E Hood, N Bashir, R Zahir New Cross Hospital, Wolverhampton, UK Critical Care 2010, 14(Suppl 1):P278 (doi: 10.1186/cc8510) Introduction In 1996, a UK audit suggested suboptimal involvement of consultant care in acute medicine [1]. Acute medicine has since evolved as a specialty to improve medical inpatient care in the irst 48 hours [2]. Many hospitals now incorporate an acute short stay unit through which up to 70% of medical admissions can be directed [3]. These units reduce the length of hospital inpatient stay [4]. Methods We conducted a review of case notes for 100 consecutive medical admissions to the Emergency Short Stay ward (ESS). Data collected included diagnoses on admission and discharge, length of stay on ESS and discharge destination. On reviewing each initial medical clerking, an assessment was made regarding the suitability of the admission to ESS, standardized against local criteria. Results Data on 100 patients (age 17 to 89) were collected. Eighty-nine per cent were admitted from the medical admissions unit, most commonly Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 for respiratory and cardiac problems. Average length of stay on ESS was 2 days. Twenty-ive per cent of patients remained on the ward for over 72 hours and 6% for over 5 days. Whilst 68% of patients were discharged home from ESS, 32% of patients were later transferred to a diferent ward. When compared with the available admissions criteria, 27% of all admissions to ESS were found to be inappropriate. Most (18/27) of these patients were later transferred to a diferent inpatient ward. Twenty-six per cent of inappropriate admissions remained on ESS for >48 hours. The total number of medical admissions to the hospital on each day of the study did not afect the number of inappropriate transfers to ESS. Conclusions The 24-bed Emergency Short Stay Ward at our UK hospital is for assessment and treatment of selected acute conditions requiring an inpatient stay <48 hours. ESS was not always being used appropriately according to the admission criteria deined by the ward managers. Hospital admissions of >72 hours are associated with signiicant increase in workload [5]. It is important that a short stay ward does not increase the length of admission by becoming a transit lounge for patients before transfer to a specialty lead ward. References 1. 2. 3. 4. 5. Houghton A, et al.: J R Coll Phys Lond 1996, 30:551-559. Dowdle JR: Emerg Med J 2004, 21:652-653. Cooke MW, et al.: Emerg Med J 2003, 20:138-142. Downing H, et al.: Clin Med 2008, 8: 8-20. Rainer TH, et al.: J Accid Emerg Med 1996, 13:325-329. P279 A study on reliability of a new triage emergency method among nursing students N Parenti1, D Sangiorgi2, V Serventi3, L Sarli3 1 Hospital Santa Maria della Scaletta Imola, Bologna, Italy; 2Università Bologna, Italy; 3Università Parma, Italy Critical Care 2010, 14(Suppl 1):P279 (doi: 10.1186/cc8511) Introduction We analysed triage reliability among nursing students at an Italian university before and after a course on a new Triage Emergency Method, TEM v2, which showed good reliability in a previous study [1]. Few studies compared triage reliability in nursing students. To our knowledge there are no Italian studies on this topic. Methods This is an observational study conducted in the University of Parma using a triage scenarios database used in previous studies [1,2]. Fifty students attending the third year of a nursing course were selected to assign a triage level to 105 paper scenarios, without triage protocols (before course) and with TEMv2 (1 month after a 2-hour course on triage and TEMv2). To prevent communication between participants, they assigned triage codes in diferent rooms, and in the presence of two investigators. The triage scenarios were given randomly to the participants. We measured: the inter-reliability using the weighted kappa statistics; the complete disagreement (when nurses of the same group assigned to the same scenario triage codes that difered in more than two priority levels); the complete agreement (when all ive nurses assigned the same triage code) before and after the course. Results Of the 105 patients included in triage scenarios, 66 (63%) were women, the mean age was 43.7 years (SD ± 26.3), and 22 were under the age of 18 years. The most frequent presentation at triage was minor trauma (30%). There were 30 hospital admissions: 27 in non-intensive wards and three in ICUs. The mean age of students was 24 ± 3 SD. Few participants attended triage training before (18%) and they declared scarce triage knowledge. Inter-rater reliability was k = 0.42 (95% CI: 0.37 to 0.46) and k = 0.61 (95% CI: 0.56 to 0.67) before the course (without triage protocol) and after the course (with TEMv2), respectively. Complete disagreement occurred in 98% of scenarios evaluated before and in 64% after the course. Complete agreement was always zero. Conclusions Our data suggest that TEM v2 improves triage reliability among nursing students. It seems to be easy to understand and to use. References 1. 2. Parenti N, et al.: Reliability and validity of two four-level emergency triage systems. Eur J Emerg Med 2009, 16:115-120. Parenti N, et al.: Aidabilità e validità di un Metodo di Triage di Pronto Soccorso a 4 codici di priorità. Emerg Care J 2008, 5:30-33. S95 P280 Aggression and violence against staf of ambulance services A Auer Vienna Ambulance Service, Vienna, Austria Critical Care 2010, 14(Suppl 1):P280 (doi: 10.1186/cc8512) Introduction Aggression and violence in the workplace have increasingly become topical for various professions in the past years. Studies, however, are mostly published for the areas of psychiatry and education. The irst part of the study investigates the question of how emergency services in general deal with aggressive assaults against their staf. In the second part, the monitoring system for aggression incidents of the Vienna Ambulance Service will be presented and evaluated. Methods By the means of an email questionnaire, 35 emergency medical services and EMS training facilities were interrogated about their procedures in case of aggression incidents. The monitoring system of the Vienna Ambulance Service, which is based on the SOAS-R questionnaire, was statistically evaluated. Results Emergency medical services survey: 21 of the 35 included organizations returned the questionnaire with usable answers. For 80% of the responding organizations, aggression against their staf is an issue; 50% installed a staf reporting system and 58% ofer de-escalation courses to their staf. Vienna Ambulance Service: during the analysis period of 2 years, 203 aggressive and/or violent assaults were reported within the Vienna Ambulance Service. In relation to the total number of 268,528 treated patients, the rate of incident is 0.08%. Males committed, with 71.7%, most of these aggressions. With regard to diagnoses, the diagnostic group of alcohol-related incidents was most frequent with 59 cases. Most events took place on weekends and in the evening hours. Verbal aggression was with 86.2% predominant; however, more than 20% of the incidents lead to physical injuries of the medical personnel. Conclusions Aggression against emergency medical service staf is brought up for discussion in many organizations. Despite several approaches in diferent states of development, standardized reporting systems are the exception. The aggression incident reporting formula of the Vienna Ambulance Service was proved to be practical for recording aggression events as well as for evaluation of de-escalation education. The study showed that aggression is a serious problem in emergency medical services and appropriate precautions need to be institutionalized. P281 Analysis of the disease spectrum of treated patients after Wenchuan earthquake Z He, Y Wangy, L Huang First Hospital Ailiated to General Hospital of PLA, Beijing, China Critical Care 2010, 14(Suppl 1):P281 (doi: 10.1186/cc8513) Introduction To investigate the data of patients treated by this ield hospital, and to analyze the rule of spectrum of diseases in Wenchuan earthquake. Methods Sexes, ages and diagnoses of the patients were collected and the percentage was respectively calculated. The amount tendencies of the time distribution of patients were also analyzed. Results Sex diferences of patients were not obvious in the total 2,331 cases. The amount in the group 15 to 60 years old, 1,535 (65.9%) cases, was signiicantly higher than those of other groups, but the relative ratios of the group 0 to 14 years old, 382 (16.4%) cases, and the group >60 years old, 414 (17.7%) cases, were higher than that of 15 to 60 years old. The top four diseases consist of respiratory system 601 (25.8%), trauma (fracture, wound or injury) 586 (24.9%), dermatology system 295 (12.7%) and others 243 (10.4%). The amount of internal medicine patients exceeded that of surgery. Conclusions The reasonable allocations of medical personnel and drugs after earthquake may help to improve the remedy results and to prevent waste of medical resource during future disasters. References 1. 2. 3. 4. Hogan DE, Burstein JL: Disaster Medicine. Lippincott Williams & Wilkins; 2003:8. Zhongjie He: The platinum ten mins – new ideal and concept. Chinese J Crit Care Med 2004, 24:745-746. Watts J: China’s health challenges after the earthquake. Lancet 2008, 371:1825-1826. Conly J, Johnston B: Natural disasters, corpses and the risk of infectious diseases. Can J Infect Dis Med Microbiol 2005, 16:269-270. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P282 Large-scale implementation of a critical care surge capacity management program BW Lawless1, J Trpkovski2 1 St Michael’s Hospital, Toronto, Canada; 2Critical Care Secretariat, Toronto, Canada Critical Care 2010, 14(Suppl 1):P282 (doi: 10.1186/cc8514) Introduction In 2003 the outbreak of severe acute respiratory syndrome (SARS) in some jurisdictions around the world highlighted a number of areas in healthcare planning that could be improved for dealing with such disasters. In Canada, one of the noted system challenges was the signiicant impact that an increase in the number of critically ill patients had on access to care and to other hospital services. Many jurisdictions have undertaken large-scale pandemic planning; however, there is a paucity of tools available to help hospitals deal with the day to day challenges of surges in patient volumes. As part of a larger comprehensive Critical Care Strategy designed to improve access to care, improve the quality of care and improve health system integration, and in partnership with hospitals and healthcare workers, the Ontario Ministry of Health and Long-Term Care designed and implemented a critical care Surge Capacity Management Program. Methods A review of the literature was completed to determine existing models for surge capacity planning. Surges were then classiied as minor, moderate or major, depending upon the increase in demand above available services and the length of time a surge situation persisted. A framework was built to incorporate surge planning on ive key elements: management, physical space, human resources, equipment and technology, and processes. A demonstration project to test the model was carried out in 18 hospitals. Hospitals collected data on patient low processes across the organization in conjunction with daily data capture in the Critical Care Information System. Based on initial success, the program was approved for a province-wide implementation. Results Critical Care Surge Resource Teams that included front-line care providers, and a senior team sponsor and a physician champion were formed to implement surge capacity plans using the standardized framework and tools. Hospitals developed plans to handle minor surges that involved increasing to 115% above their normal operating capacity. This program has involved 201 critical care units in 150 hospitals across the province. Conclusions This program represents one of the largest implementations of a standardized Surge Capacity Program for managing critical care resources in a time of crisis. The program has seen practical use during the recent experience with H1N1 with improved access to care for patients. P283 Standard X-rays for the victims of severe trauma: time for a change E Cingolani, C Siddi, G Ranaldi, L Nocilli, S Rogante, A Stasolla, G Nardi Azienda Ospedaliera San Camillo Forlanini, Rome, Italy Critical Care 2010, 14(Suppl 1):P283 (doi: 10.1186/cc8515) Introduction International guidelines for trauma care still recommend the traditional advanced trauma life support investigations for the primary survey: plain radiographs of the chest, cervical spine and pelvis with FAST ultrasounds. However, an increasing amount of data suggest that plain X-rays have excessively low sensitivity. Cervical X-ray may miss up to 35% of the spine injuries, chest X-ray may miss as many as many as 50% of traumatic pneumothorax and a signiicant percentage of pelvic fractures may not be detected on the pelvis X-ray. CT scan and extended emergency ultrasound (EUs) have a much higher sensitivity if compared with plain X-rays. Moreover, EUs is even less time consuming. Therefore since 2004 we have adopted EUs and/or total body CT scan as the irstline diagnostic tools for major trauma (MT) victims. In a benchmarking analysis of Italian trauma centers (TCs), our hospital ranked irst for patient mortality and long-term disability [1]. These results were associated with the shortest diagnostic time. The aim of this study is to assess whether these results were associated with a real change in the diagnostic process. Methods In order to evaluate the diagnostic approach to MT we retrospectively analyzed all MT cases (ISS >15) admitted to our TC over a 2-year time span. All investigations performed in the emergency department (ED) are entered in an electronic shift just before being S96 performed. Data for all investigations requested within 2 hours from admission were analyzed. Results From 1 November 2007 to 31 October 2009, 743 MT patients were admitted to the ED. EUs was performed in 515 patients (69%), total body CT scan in 679 (91%). Patients who were not submitted to CT either died soon after admission or were rushed to the operating room on the basis of EUs results. Thirty-eight patients had a chest X-ray taken in the ED (5.1%), 11 (1.5%) a pelvic X-ray and only three a cervical spine X-ray. Conclusions Although many international guidelines for trauma care still recommend traditional plain radiographic investigations, our TC as well as many other European institutions with a high volume of trauma patients have adopted a diferent strategy based on the extended use of EUs and CT scan. This may improve the accuracy of the diagnosis in the stabilized patients and reduce time to the operating room in the highly instable ones. We suggest that a change in the recommended guidelines should be considered. Reference 1. Di Bartolomeo S, et al.: Injury 2007, 38:305-311. P284 Focused assessment with sonography for trauma in the prehospital setting R Egashira, N Saito, H Matumoto, K Mashiko Chiba Hokuso Hospital, Nippon Medical School, Chiba, Japan Critical Care 2010, 14(Suppl 1):P284 (doi: 10.1186/cc8516) Introduction Previous studies have focused on the accuracy of the focused assessment with sonography for trauma (FAST) examination performed in the emergency department (ED), but have not evaluated FAST performed in the ield setting (ield FAST). We aimed to evaluate the accuracy of ield FAST by comparison with FAST performed in the ED. Methods A total of 1,380 trauma patients were admitted to our hospital by air ambulance between April 2005 and October 2009. We compared the sensitivity and speciicity of ield FAST with those of FAST in the hospital setting. The presence of pericardial and intraperitoneal luid was conirmed by the medical records. Results Of these patients, 317 blunt trauma patients (mean age, 43.9 ± 23.8 (SD) years) were examined by ield FAST and enrolled in the study; all participants were also examined by FAST in the ED. The mean Injury Severity Score was 16.1 ± 15.4 (SD). Forty-seven patients (14.8%) were ultimately diagnosed with pericardial and intraperitoneal luid. Field FAST detected 12 of these cases. The sensitivity of ield FAST was signiicantly lower than that of FAST in the ED (P <0.01), whereas the speciicities of FAST in the two settings were not signiicantly diferent. Emergency surgery was performed in nine of the 12 patients who were positive with ield FAST. Table 1 (abstract P284) Field FAST ED FAST P value Sensitivity 28.9% 66.7% <0.01 Speciicity 97.0% 96.6% 0.76 Conclusions Because the sensitivity of ield FAST is low, repeated examination in ED is needed to improve diagnostic sensitivity. However, ield FAST may be an efective tool for early detection of critical blunt trauma and as a rapid indicator for surgery. P285 Clinicopathogenetic aspects of systemic inlammatory response development in polytrauma I Ustyantseva, O Khokholva, V Agadzhanyan, O Petukhova, Y Zhevlakova Federal State Medical Prophylactic Institution ‘Scientiic Clinical Center of Miners’ Health Protection’, Leninsk-Kuznetsky, Russia Federation Critical Care 2010, 14(Suppl 1):P285 (doi: 10.1186/cc8517) Introduction The aim of the study was identiication of common regularities and pathogenetic signiicance of changes in the ratio between primary and secondary inlammatory mediators in development of systemic inlammatory response syndrome (SIRS) in polytrauma. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Methods Three hundred and eighty-seven patients with polytrauma hospitalized to the ICU were examined. There was infection conirmed by microbiology in 175 (pneumonia, bronchitis, osteomyellitis, acute urethritis, and so forth); 212 patients had no infection (acute respiratory distress syndrome, disseminated intravascular coagulation, fat embolism, and so forth). In 87% two or more signs of SIRS were noted according to the criteria of the Consensus Conference ACCP/SCCM (2003). C-reactive protein (CRP) in venous blood serum was measured on 1, 3, 5, 7, 10, 15 and 17 days after admission using the biochemical analyzer HITACI-912 with reagents Tina-Quant CRP (Roche Diagnostic GMBH), lipopolysaccharidebinding protein (LPSBP) and cytokines TNFα, IL-2R, IL-6, IL-8, IL-10 using the immunochemiluminescent analyzer IMMULITE with the reagents DPC (USA). Constant variables were compared using Student’s t test and the Mann–Whitney U test. The diferences were signiicant at P <0.05. Results On admission, increased serum LPSBP and TNFα were noted in all patients with infection compared with the patients without it (1.8 and 3 times respectively, P <0.01). Moreover, the infectious patients had the apparent increase of IL-2R, IL-6, IL-8 and CRP: 5, 13, 18 and 5 times, respectively (P <0.05). At that, generalized manifestation of inlammatory reaction in the infectious patients was characterized by at mean ivefold increase in IL-8 on day 3 of the follow-up. It was not accompanied by adequate anti-inlammatory response that was indicated by an absence of IL-10 dynamics. A direct correlation was found between an increase in inlammatory mediator concentration (IL-6, IL-8, IL-10) and respiratory rate (r = 0.73; 0.46; 0.59), CRP and heart rate (r = 0.48, P <0.05), and an inverse correlation between inlammatory mediators (TNFα, IL-2R, LPSPB) and arterial pressure level (r = –0.42; –0.63; –0.48) and respiratory function values (vital lung capacity and forced expiratory volume, r = –0.42). Conclusions Hyperproduction of proinlammatory cytokines is closely connected with ventilation disturbances and clinical variants of the posttraumatic period course in patients with polytrauma. P286 Diagnostic and prognostic signiicance of serum apoptosis markers in the patients with severe trauma injury EG Grigoryev1, AR Radivilko1, AK Kiseleva2, YC Churliaev2, GV Vavin1 1 Kemerovo State Medical Academy, Kemerovo, Russia Federation; 2Branch of Scientiic Institute of General Reanimatology RAMS, Novokuznetck, Russia Federation Critical Care 2010, 14(Suppl 1):P286 (doi: 10.1186/cc8518) Introduction The aim of the investigation was to analyze the diagnostic and prognostic signiicance of serum proapoptosis and antiapoptosis markers in the patients with severe trauma injury. Methods Thirty-three patients with severe trauma injury were enrolled into our investigation (we excluded patients with severe brain injury, the middle age was 39 ± 8, initial TRISS scale 7.8 ± 1.8, APACHE II 14 ± 5). All of the patients demonstrated signs of systemic inlammatory response, in 12 patients the infectious pulmonary complications were revealed and in 21 patients the infectious complications were not developed. Venous blood serum EDTA samples were investigated every day during a week in the –25°C freeze. We investigated antiapoptotic markers (soluble Fas-L, soluble APO-1/Fas, Cu/Zn superoxide dismutase), proapoptotic markers (protein p53, protein Bcl-2), and high-sensitivity CRP (ELISA, Bender Medsystem). Results We observed an increase in proapoptotic markers in patients with infectious complications from the irst day in the ICU, antiapoptotic markers (Cu/Zn superoxide dismutase) were lower with regard to reference points. The patients demonstrated a maximum of Fas-L, protein p53, and protein Bcl-2 (near 50% relative to irst day) on the second day. In patients without infection complications we identiied a decreased level of proapoptotic markers and an increased level of antiapoptotic markers (SOD, soluble Fas-L, soluble APO-1/Fas). High-sensitivity CRP correlated with the severity of infectious complications. Conclusions Serum proapoptotic and antiapoptotic markers have demonstrated diagnostic and prognostic signiicance in the patients with severe trauma injury. Reference 1. De Freitas I, Fernández-Somoza M, Essenfeld-Sekler E, et al.: Serum levels of the apoptosis-associated molecules, tumor necrosis factor-alfa/tumor necrosis factor type-I receptor and Fas/FasL, in sepsis. Chest 2004, 125:2238-2246. S97 P287 Predictors of mechanical ventilation after burn injury A Pirat, P Zeyneloglu, A Kundakci, C Aydogan, G Arslan, M Haberal Baskent University Faculty of Medicine, Ankara, Turkey Critical Care 2010, 14(Suppl 1):P287 (doi: 10.1186/cc8519) Introduction It is important to predict the need for mechanical ventilation (MV) in burn patients in order to improve their management and also to optimize resource ultilization. However, there are scant data on the predictors of MV in burn patients. The purpose of this study was to determine the risk factors for MV in a cohort of our burn patients. Methods A retrospective chart review was completed for patients admitted to Baskent University Burn Institute, from January 2003 through December 2008. Patients were divided into two groups based on whether they required MV during their irst 3 days of hospitalization or not. After comparing the two groups for the recorded variables, a binary logistic regression model was developed using statistical and clinical signiicance to identify the risk factors for MV. Results Out of 160 patients, 33 patients (21%) required MV during their irst 3 days of hospitalization. Patients who required MV were similar to those who did not in terms of demographic features. Patients who required MV were signiicantly diferent from those who did not regarding the mean burn percentage (56% ± 23% vs 19% ± 15%, P <0.001), mechanism of burn (lame, 73% vs 37%, P = 0.001), inhalational injury (27% vs 3%, P <0.001), and burn afecting head and neck (72% vs 37%, P <0.001). Binary logistic regression revealed that inhalational injury (OR, 8.4; 95% CI, 1.1 to 66.1; P = 0.042) and burn percentage (OR, 1.1; 95% CI, 1.1 to 1.2; P <0.001) were independent risk factors for MV. Conclusions Our results demonstrate that inhalational injury and burn percentage are predictors of MV in our series of burn patients. Particularly, patients with inhalational injury were eight times more likely to require MV during their irst 3 days of hospitalization in our series. P288 Impact of regional imaging guidelines for head injury and unconscious polytrauma patients R Gibbs1, R Walker2, E Thomas3 1 Musgrove Park Hospital, Taunton, UK; 2Torbay Hospital, Torbay, UK; 3Derriford Hospital, Plymouth, UK Critical Care 2010, 14(Suppl 1):P288 (doi: 10.1186/cc8520) Introduction Inadequate or delayed imaging of the unconscious patient with traumatic brain injury or of the unconscious polytrauma patient may lead to catastrophic consequences. The need for comprehensive imaging needs to be balanced against the patient’s condition, the resources available and excessive radiation exposure. We have introduced regional evidence-based guidelines in the Southwest region of the UK. The aim of these guidelines was to standardise practice, minimise delayed or missed diagnosis of serious injuries, facilitate treatment of associated injuries (such as head injuries) and to obviate the need for repeated imaging. Methods The notes of all unconscious polytrauma patients transferred from the emergency department or other hospitals and all patients transferred to our institution for ongoing neurosurgical care were retrospectively reviewed over a 1-year period. Adherence to the imaging protocol was assessed and the need for any further radiological investigations within 48 hours was also documented. Results A total of 46 patients were identiied who fulilled the criteria for the introduced guidelines. Of these patients, 21% were transferred from other hospitals while the remainder was admitted from the onsite emergency department. Eighty-three per cent of all eligible patients adhered to the protocol. Two patients (4%) required further radiological investigation in the 48 hours following admission. Both had isolated head injury and required further imaging to exclude cervical injuries following inadequate imaging which did not follow protocol. One further patient (2%) required repeated imaging to exclude mesenteric injury. Conclusions Regional adoption of imaging guidelines aimed at obtaining early comprehensive imaging of both head-injured and polytrauma patients results in high compliance and a low rate of re-imaging. References 1. 2. Trauma: Who Cares? NCEPOD; 2009. Efect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet 2009, 373:1455-1461. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S98 P289 Blunt vascular injuries of the carotid and vertebral arteries: should we screen the asymptomatic trauma patients at high risk? Preliminary results of a prospective cohort study G Nardi, C Alessandrini, C Siddi, S Rogante, L Nocilli, G Ranaldi, E Cingolani, V Miele Azienda Ospedaliera S Camillo Forlanini, Rome, Italy Critical Care 2010, 14(Suppl 1):P289 (doi: 10.1186/cc8521) Introduction Blunt cerebrovascular injuries (BCVI) are more common than previously reported and, if not promptly recognized and treated, may have devastating sequelae. When these injuries are diagnosed before the onset of stroke, and patients receive early antiplatelet or anticoagulation therapy, a substantial reduction in BCVI-related neurologic events has been demonstrated [1]. Methods The study setting was a level 1 trauma center with a catchment population of more than 2 million people, admitting 350 major traumas yearly. To assess the incidence of asymptomatic BCVI in the severely injured patients, we planned a prospective cohort study. According to the study design, all of the severely injured patients presenting with at least one of the following criteria [2] were submitted to a screening 16-channel CT angiography within 24 hours from admission: difuse axonal injuries; fracture of the cervical vertebrae or of the skull base; Lefort II or III or other severe facial fractures. Results During the irst 5 months of the study, 24 major trauma patients (ISS >15) with at least one of the above listed risk factors were submitted to a screening CT angiography for BCVI. All of the patients were sedated and artiicially ventilated. None of them was symptomatic for stroke. Three patients (12.5%) in this high-risk group had an asymptomatic BCVI: pseudoaneurysm (one), traumatic stenosis (one) or dissection (one) of the carotid artery. They were immediately treated with antiplatelet therapy (clopidogrel + aspirin). They experienced no episodes of cerebral infarction and no cerebral haemorrhage. Conclusions There are limited data in the literature on traumatic BCVI. The available data as well as the preliminary results of our prospective study show that BCVI are more common than previously recognized. Aggressive screening and earlier therapy may signiicantly reduce complications and improve patient outcomes. References 1. 2. Edward N, et al.: J Am Coll Surg 2007, 204:1007-1015. Utter GH, et al.: J Am Coll Surg 2006, 203:838-848. P290 Efect of 8.4% sodium bicarbonate on raised intracranial pressure after traumatic brain injury C Bourdeaux, J Brown Frenchay Hospital, Bristol, UK Critical Care 2010, 14(Suppl 1):P290 (doi: 10.1186/cc8522) Introduction The aim of this study was to determine the eicacy of 8.4% sodium bicarbonate for intracranial pressure (ICP) reduction in adult patients with severe traumatic brain injury (TBI) and intracranial hypertension. Methods The study examined 10 episodes of ICP >20 mmHg in seven patients with severe TBI. Eighty-ive milliliters of 8.4% sodium bicarbonate was infused over 30 minutes when osmotherapy was indicated after standard care. ICP, mean arterial pressure (MAP), and cerebral perfusion pressure (CPP) were recorded at baseline and then continuously for 6 hours. Serum pH, pCO2, (Na+), and (Cl–) were measured at baseline, 30 minutes, 60 minutes and then hourly for 6 hours. Serum osmolality was measured at baseline and at 6 hours in three patients. All other care was identical to the institutional protocol for the management of raised ICP. Results At the completion of the infusion, the mean ICP was reduced to 36.2% of baseline, from 28.5 mmHg (±2.62) to 10.33 mmHg (±1.89). Mean ICP remained below 20 mmHg for 6 hours (Figure 1). CPP was increased after the infusion due to the efect on ICP. MAP did not change. Mean pH was elevated at t = 30 minutes (from 7.45 ± 0.02 to 7.50 ± 0.02) and remained elevated for the duration of the study period. Serum (Na+) increased (from 145.4 ± 1.9 mOsm/l to 147.1 ± 1.9 mOsm/l) at 30 minutes. pCO2 did not change. Osmolality was elevated. Figure 1 (abstract P290). Conclusions Eighty-ive milliliters of 8.4% sodium bicarbonate infused over 30 minutes is efective at reducing sustained ICP >20 mmHg to within accepted treatment targets (ICP <20 mmHg) for at least 6 hours. P291 Hypernatremia in pediatric patients with severe traumatic brain injury D Azovskiy1, A Lekmanov2, S Pilyutik1, E Gegueva2 1 Speranskiy Children’s Hospital, Moscow, Russia Federation; 2Moscow Research Institute of Pediatric Surgery, Moscow, Russia Federation Critical Care 2010, 14(Suppl 1):P291 (doi: 10.1186/cc8523) Introduction Water–electrolyte imbalance and endocrine disorders make the problem of maintaining patients with severe traumatic brain injury (TBI) more diicult. A plasma sodium level ≥160 mmol/l is associated with 75% mortality. The purpose of this investigation was to ind the relationship between hypernatraemia and the rate of unfavorable outcomes in children with TBI. Methods A total of 77 children <18 years of age with TBI (admission GCS score <8) were divided retrospectively into three groups: Group A included children without hypernatraemia (n = 51), Group B children with hypernatraemia (n = 14) and Group C (n = 12) children with hypernatraemia and polyuria. Group C was considered the group of patients with central diabetes insipidus (CDI). Hypernatraemia was deined as a twice elevation of the plasma sodium level over 149 mmol/l within 24 hours, while polyuria was deined as an increase in the hourly diuresis of more than 3 ml/kg/hour in no less than 6 hours. Results The mean sodium level at admission was 140.1 ± 4.1 mmol/l. Hypernatraemia was detected in 26 patients (33.8%). The mean duration of the period of hypernatraemia in Group B was 4 days (3 to 6 days), while the mean sodium level during the period of hypernatraemia was 158.3 ± 3.3 mmol/l (max 176.8 mmol/l). The duration of the period of hypernatraemia in Group C was 4.5 days with max 181.1 mmol/l and average 161 ± 4.7 mmol/l. Polyuria was diagnosed in 15.5% of the cases. The highest diuresis in this group was 4.1 mmol/kg/hour, mean 3.7 ± 0.5 ml/kg/hour. Such changes were considered a manifestation of CDI. All 12 patients in Group C received desmopressin (DDAVP) for more than 48 hours (mean 56.8 ± 4. 5 hours). The doses were 0.025 to 0.2 mg/day. In four out of 14 children in Group B (29%), an increase hourly diuresis up to 3 ml/kg/hour was considered the onset of CDI; thus, they were also prescribed DDAVP. Unfavorable outcomes (GOS score 1 to 3) during a 30-day assessment were observed only in Groups B and C. In a comparison of unsuccessful outcomes between Groups B and C, there was an increase in the unfavorable outcome rate in patients of Group C (with hypernatraemia and polyuria) – 10 children (84%) and Group B – four children (28%). The risk factor in the comparison between patients of Groups B and C was 0.3, P <0.05. Conclusions Our results demonstrate that hypernatraemia increases the rate of unfavorable outcomes in children with TBI. Thirty-day outcomes were worse with CDI patients. Presumably, the used of DDAVP prevents dehydration and CDI advance. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S99 P292 Use of transcranial Doppler in patients with severe traumatic brain injury D Ziegler, G Cravens, G Angles, R Gandhi, P Cho John Peter Smith Hospital, Fort Worth, TX, USA Critical Care 2010, 14(Suppl 1):P292 (doi: 10.1186/cc8524) Introduction Secondary ischemic insult after severe traumatic brain injury (TBI) is correlated with poor outcome. Transcranial Doppler sonography (TCD) permits a non-invasive measurement of cerebral blood low. The purpose of this study is to determine the usefulness of TCD in patients with severe TBI. Methods TCD was performed on 73 patients with severe TBI, deined as a Glasgow Coma Scale of 8 or less on admission. All patients were on mechanical ventilation. TCD was performed on hospital days 1, 2, 3 and 7. Hypoperfusion was deined by having two out of three of the following: mean velocity of the middle cerebral artery less than 35 cm/ second, diastolic velocity of the middle cerebral artery less than 20 cm/ second and a pulsatility index greater than 1.4. Vasospasm was deined by the following: mean velocity of the middle cerebral artery greater than 120 cm/second and/or Landegaard index greater than 3. Results Thirty-four patients (64%) had normal measurements. Thirteen were discharged home, 16 were discharged to a long-term care facility and ive died. Two of these patients were comatose and their families requested withdrawal of care. The other three died from brain death. Eighteen patients (25%) had hypoperfusion and all 18 progressed to brain death. Twenty-one patients (29%) had vasospasm. Four of these patients were discharged home, 11 to a long-term care facility and six died. The vasospasm was detected on hospital day 1 in three patients, hospital day 2 in seven patients, hospital day 3 in four patients and hospital day 7 in seven patients. Nimodipine was administered in six patients and all six were discharged to a long-term care facility. However, in one patient, nimodipine caused hemodynamic instability and was discontinued. In 15 patients, nimodipine was not given. Six of these patients expired from brain death. Twelve of 21 patients (57%) with subarachnoid hemorrhage on computed tomography had vasospasm. Conclusions Most patients with normal measurements can be expected to survive. Patients with hypoperfusion have a poor prognosis. In patients with vasospasm, the use of nimodipine should be considered; however, further studies are needed to determine safety and eicacy. TCD may be useful in determining early prognosis. Further studies are also needed to determine whether TCD can improve outcome in patients with severe TBI. P293 Abstract withdrawn P294 Efect of hyperbaric oxygen on cerebral oxygen saturation in patients with sub-acute traumatic brain injury L Liu, B Zhou, B Liu Second Ailiated Hospital of Soochow University, Suzhou, China Critical Care 2010, 14(Suppl 1):P294 (doi: 10.1186/cc8526) Introduction How hyperbaric oxygen (HBO) afects injured brain tissue is not yet conirmed. We suppose that HBO could make the oxygen stay longer in the injured tissue, because of poor circulation or perfusion of blood in the injured area. This mechanism may help to explain the longer efect of HBO, after HBO treatment. That is the purpose of our study. Methods Patients sufering from sub-acute traumatic brain injury, who would be treated with HBO, were enrolled in the study. They were divided into two groups: frontal lobe lesion and nonfrontal lobe lesion groups (n = 20) depending on their iconography check (X-CT or MR). The regional cerebral oxygen saturation (rSO2) was measured by a Somanetics INVOS 5100 monitor before and after 90 minutes treatment with HBO (15 minutes compression, 40 minutes breathing oxygen of FiO2 99% by mask, 10 minutes rest, 15 minutes decompression). Meanwhile, the arterial blood was sampled to measure blood gas analysis and cytokine. Results The parameter of rSO2 showed no signiicant diference following HBO treatment in two groups (t = 0.352, P >0.05); however, there were inconceivable results in blood gas analysis. Partial pressure of oxygen (PaO2) was signiicantly decreased after HBO treatment (P <0.05), although these changes did not take efect on the clinical manifestation. Otherwise, the measurement of cytokines (TNF, IL-1) before and after HBO has no diference (P >0.05) in all groups. Conclusions HBO has no efect on brain oxygen saturation, after HBO treatment. But PaO2 was signiicantly decreased following HBO. The mechanism needs to be studied further. Reference 1. Allen BW, et al.: Two faces of nitric oxide: implications for cellular mechanisms of oxygen toxicity. J Appl Physiol 2009, 106:662-667. P295 Brain biomarkers and brain tissue oxygenation: changes and correlations following severe head injury S Mondello1, A Buki2, R Bullock3, CS Robertson4, E Czeiter2, E Ezer2, FC Tortella5, KK Wang1, RL Hayes1 1 Banyan Biomarkers and University of Florida, Alachua, FL, USA; 2University of Pecs, Hungary; 3University of Miami, FL, USA; 4Baylor College of Medicine, Houston, TX, USA; 5Walter Reed Army Institute of Research, Silver Spring, MD, USA Critical Care 2010, 14(Suppl 1):P295 (doi: 10.1186/cc8527) Introduction This study evaluated relationships between CSF levels of brain biomarkers, glial ibrillary acidic protein (GFAP), ubiquitin C-terminal hydrolase (UCH-L1) and αII-spectrin breakdown (SBDP145), partial pressure of brain tissue oxygen (ptiO2) and brain temperature (Licox system) during the irst 24 hours and for up to 10 days following severe TBI. Methods We studied 27 severe TBI patients having CSF drainage and invasive monitoring of partial brain tissue oxygen tension (PbtO2) and brain temperature using the Licox (Integra Neurosciences, Plainsboro, NJ, USA) probe. CSF SBDP145, UCH-L1 and GFAP levels were measured by quantitative ELISA assay on admission and every 6 hours thereafter for a maximum of 10 days. Using a double lumen bolt, ptiO2 and temperature were measured with the Licox. This study focused on the recordings of the irst 24 hours following injury (27 patients), as well as preliminary data from four patients for 10 days. Results The total duration of monitoring was 1,512 hours. During the irst 24 hours, biomarker levels decreased while levels of PbrO2 increased. All three biomarkers correlated with PbrO2 (P <0.0001, P = 0.016 and P = 0.023, respectively). After the irst 24 hours, there were statistically signiicant changes in levels of brain biomarkers (SBDP145, UCH-L1 and GFAP) as well as in levels of ptiO2 (respectively, P = 0.025, P <0.0001, P = 0.033, P <0.0001). However, the correlation between biomarkers and brain tissue oxygenation was sustained, and for UCH-L1 improved (P <0.0001). No signiicant correlations between biomarker levels and brain temperature were found. There were no complications from the monitoring. Conclusions Our indings show that CFS levels of SBDP145, UCH-L1 and GFAP are related to brain tissue oxygenation in acute and possibly the subacute (≤10 days post injury) phases of severe TBI. Future studies will more directly address relationships between changes in tissue oxygenation and biochemical markers of injury following severe TBI. CSF levels of biomarkers and brain tissue oxygenation could yield insights into pathophysiological events following severe TBI and aid in clinical assessments of severe TBI patients. Table 1 (abstract P294) pH Group PaO2 (mmHg) PaCO2 (mmHg) Pre Post Pre Post Pre Post Frontal lobe lesion 7.42 ± 0.02 7.45 ± 0.04 135.4 ± 29.77 102.12 ± 9.08 43.69 ± 4.58 40.81 ± 7.53 Nonfrontal lobe lesion 7.41 ± 0.03 7.42 ± 0.04 128.2 ± 34.22 107.2 ± 24.00 43.93 ± 4.88 43.00 ± 4.80 Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P296 Cortex and deep grey matter have diferent sensitivities to hypoxia-hypotension and traumatic brain injury: a combined PtiO2 and microdialysis study in rats A Odri, B Vigué, J Duranteau, T Geeraerts CHU de Bicetre, Le Kremlin Bicetre, France Critical Care 2010, 14(Suppl 1):P296 (doi: 10.1186/cc8528) Introduction After traumatic brain injury (TBI), structural lesions are heterogeneous, but the spatial heterogeneity of consequences of insults as hypoxia-hypotension (HH) and/or TBI has never been studied. The objective of this study was to compare the efect of standardized insults (HH, TBI and both) on brain energy metabolism in two diferent regions: frontal cortex and thalamus. Methods Twenty-eight Sprague–Dawley rats were randomized into four groups: Sham, TBI (impact acceleration alone, 450 g weight drop from 1.8 m), HH (blood depletion to mean arterial pressure 40 mmHg, FiO2 10%, 15 minutes) and TBI-HH (TBI followed by HH, 45 minute delay). Cerebral perfusion pressure (CPP) was continuously and invasively measured. Brain microdialysis and PtiO2 probes were both inserted stereotaxically in the right thalamus and frontal cortex. Results Except during the HH phase, CPP was always greater than 60 mmHg. During the hour following the HH period, a signiicant increase in cerebral lactate/pyruvate ratio (Figure 1), glycerol and glutamate was observed. This increase was higher in the cortex than in the thalamus in all groups subjected to HH (P <0.001). In the TBI-HH groups, the increase in glycerol in the cortex was signiicantly higher compared with the HH group (P <0.001), as well as thalamic and cortical glutamate. During 15 minutes following the HH phase (after reinjection and reoxygenation), an increase in PtiO2 was observed in the cortex and thalamus, but with diferent proiles (lower increase in the cortex) (Figure 1). Conclusions Diferent proiles of cerebral response to HH and TBI were observed with higher sensitivity in the cortex than in the thalamus. The post-ischemic hyperemia seems to be altered in the traumatized cortex but conserved into the thalamus and nontraumatized brain. P297 Diagnosis of carotid and vertebral artery injury in major trauma with head injury A Circelli1, M Ciapetti2, R Spina2, A Pasquini2, L Migliaccio2, M Pierini3, G Zagli2, A Peris2 1 Postgraduate School of Anesthesia and Intensive Care, University of Florence, Italy; 2Careggi Teaching Hospital, Florence, Italy; 3Mechanical and Technology Department, University of Florence, Italy Critical Care 2010, 14(Suppl 1):P297 (doi: 10.1186/cc8529) Introduction The purpose of this study is to describe a single institutional experience in diagnosis and management of patients with blunt cerebrovascular injury (BCVI) after severe traumatic brain injury (TBI). S100 Methods We considered blunt major trauma patients consecutively admitted from January 2008 to October 2009 to our ICU of a regional referral hospital (Careggi Teaching Hospital, Florence, Italy). Patients were screened on the basis of Memphis criteria to identify risk factors for BCVI: complex cervical spine fractures, neurological conditions not sustained by imaging, Horner’s syndrome, LeFort II/III fractures, basilar skull fractures with petrous/ neck soft tissue injury. We modiied this protocol to investigate all petrous fracture and to consider also cervical spine fractures (subluxation, transverse foramen, upper cervical spine involvement). In all patients judged at risk for BCVI, a 64-slice angio-CT scan (CTA) was performed. Results During the study period, 266 patients were admitted to the ICU for BMT with an ISS >15; 162 patients (60.9%) presented TBI or cervical spine fracture. According to our proposed modiied Memphis criteria, 46 patients showed risk factors for BCVI (17.3% of the total of BMT; 28.4% of TBI), and six of them had carotid injury (2.2% of all BMT; 13.0% of patients with risk factors). No vertebral injury was detected. Anticoagulant therapy within 72 hours was initiated in all patients. No complications occurred and all patients were discharged from the ICU. Clinical examination during the 6-month follow-up showed no neurological deiciency related to previous vascular injury. Conclusions A higher percentage of BCVI was observed using the proposed modiied Memphis criteria if compared with other studies (2.2% vs 1%). The mortality rate was lower than previously reported for patients with BCVI (0% vs 13%) and it could be explained by the early diagnosis and anticoagulant therapy initiation. An extended screening protocol application allows prompt recognition of BCVI. In regard of the higher percentage of BCVI found in our population, an advanced study on protective devices (for example, helmets) is actually in progress with the aim to reduce biomechanical efects of head injury on extracranial vessels. P298 Decompressive craniectomy in severe intracranial hypertension after brain injury: early or late? S diValvasone1, S Biondi2, A Nella2, L Migliaccio2, M Ciapetti2, G Cianchi2, M Bonizzoli2, G Zagli2, F Mariotti2, F Posteraro3, A Peris2 1 Postgraduate School of Anesthesia and Intensive Care, University of Florence, Italy; 2Careggi Teaching Hospital, Florence, Italy; 3Auxilium Vitae, Volterra, Italy Critical Care 2010, 14(Suppl 1):P298 (doi: 10.1186/cc8530) Introduction Decompressive craniectomy is indicated for treatment of severe intracranial hypertension. However, this procedure is invasive and potentially associated with complications. We present a preliminary result of a study comparing early and late decompressive craniectomy in severe traumatic brain injury. Methods Patients studied were all admitted to the ICU of a tertiary referral center (Careggi Teaching Hospital, Florence, Italy) during 4 years (2005 to 2009). In total, data of 62 brain-injured patients, who underwent decompressive craniectomy, were retrospectively examined and included in two groups based on decompressive craniectomy execution: Figure 1 (abstract P296). Brain lactate/pyruvate ratios and PtiO2 in the thalamus and cortex. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S101 Figure 1 (abstract P298). Demographic and clinical characteristics of both groups. early decompressive craniectomy group (decompressive craniectomy performed within 24 hours after brain injury, group A; n = 41) and late decompressive craniectomy (later than 24 hours, group B; n = 21). For all patients, demographic, scores, clinical data, length of stay and inal outcome were collected from the institutional database. Traumatic lesions were compared at admission using the Marshall score and 24 hours after decompressive craniectomy execution with CT scan. The Glasgow Outcome Scale (GOS) at 6 months was also collected. Results Demographic and clinical characteristics of groups are shown in Figure 1 (data expressed as mean ± SD). Patients who underwent decompressive craniectomy within 24 hours after injury (group A) had a signiicant worst Marshall score if compared with group B (3.1 ± 0.7 vs 2.4 ± 0.8, respectively; P <0.05), but also showed a signiicant enlargement of contusions compared with group B (52.7% vs 16.6%; P <0.01). ICU/ hospital length of stay and mortality were not signiicantly diferent between groups. The GOS evaluated at 6 months showed a good recovery of surviving patients in both groups (3.7 ± 1.0 in group A and 3.2 ± 0.9 in group B). Conclusions Our data, limited by the retrospective nature of the study, do not encourage an early decompressive treatment of severe intracranial hypertension. Decompressive craniectomy should be considered in case of lack of response to a medical, even intensive, approach. References 1. 2. Neurosurg Focus 2009, 26:E7. Curr Opin Crit Care 2007, 13:163-168. P299 Abstract withdrawn P300 Optic nerve ultrasound for detecting intracranial hypertension V Orzalesi, L Bucciardini, A Amadori, S Marchiani, P Innocenti AOU Careggi, Florence, Italy Critical Care 2010, 14(Suppl 1):P300 (doi: 10.1186/cc8532) Introduction The purpose of this study is to verify the reliability of optic nerve ultrasound (ONU) for detecting intracranial hypertension (IH). IH is a frequent and potentially fatal complication of severe head injury. Actually, intraventricular catheters represent the gold standard for ICP measurements. Unfortunately they present serious complications and relative contraindications like thrombocytopenia or coagulopathy. Computed tomography and transcranial Doppler (TCD) represent noninvasive methods to evaluate ICP but they present drawbacks. ONU has been recently suggested as a non-invasive tool to diagnose IH. Its reliability has been showed in patients with severe head injury or with intracranial hemorrhage [1,2]. Methods The study was conducted on 10 patients admitted to the neurointensive care unit for moderate/severe head injury in the period January to June 2009 (Group 1). Ten healthy subjects were enrolled as the control group (Group 2). Estimated ICP (eICP) was calculated with TCD using the equation proposed by Czosnyka and colleagues [3]. It was measured twice a day for 3 consecutive days. In the same sonographic session, the optic nerve sheath diameter (ONSD) was measured in the sagittal and transverse plane 3 mm behind the papilla, in both eyes. Results No signiicant diferences have been found between groups regarding age and sex. The ONSD distribution is shown in Figure 1. ONSD, eICP and ICP values were signiicantly higher in Group 1 than in Group 2. Linear regression analysis identiied a signiicant relationship Figure 1 (abstract P300). ONSD distribution in patients with ICP less than and more than 20 mmHg. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 between ONSD and ICP (r = 0.588). By calculating the receiver operating characteristic curve, an ONSD value of 5.35 mm resulted as the optimal cut-of point with a sensitivity of 95.1% and a speciicity of 96.2%. Conclusions ONSD measurements correlated with invasive and noninvasive (TCD) measurements of ICP. It is a useful, non-invasive bedside tool to diagnose IH. It is safe, easy to perform and can rapidly give reproducible information on patients’ ICP. References 1. 2. 3. Moretti R, et al.: Reliability of optic nerve ultrasound for the evaluation of patients with spontaneous intracranial hemorrhage. Neurocrit Care 2009. [Epub ahead of print] Geeraerts, et al.: Non-invasive assessment of intracranial pressure using ocular sonography in neurocritical care patients. Intensive Care Med 2008, 34:2062-2067. Czosnyka M, et al.: Cerebral perfusion pressure in head-injured patients: a noninvasive assessment using transcranial Doppler ultrasonography. J Neurosurg 1998, 88:802-808. P301 Measurement of neuronal speciic enolase as a predictor of outcome in patients sufering from severe traumatic brain injury JW Gatson, AH Idris, PE Pepe, JP Minei, J Wigginton University of Texas Southwestern Medical Center at Dallas and the Parkland Health and Hospital System, Dallas, TX, USA Critical Care 2010, 14(Suppl 1):P301 (doi: 10.1186/cc8533) Introduction Traumatic brain injury (TBI) is a multiphasic disease. Following the initial impact, secondary injury, including oxidative stress and inlammation, is thought to contribute signiicantly to death and disability. This ongoing damage in the penumbra of the brain leads to the demise of neuronal populations, and ultimately decreased brain function. Identiication of various neural markers such as neuronal speciic enolase (NSE) at various time points following TBI may help us better understand the magnitude of secondary injury following TBI, and may help predict outcome in these patients. Methods Early serial cerebrospinal luid (CSF) samples were collected from patients with severe TBI (GCS 3 to 8) who required placement of a therapeutic ventriculostomy. Following ventriculostomy placement, CSF samples were obtained every 4 hours for the irst 24 hours post-injury, then every 8 hours for post-injury days 2 to 5. The levels of NSE were then measured using the ELISA method. Results Following sample analysis in 11 patients, we found that in TBI patients that had a good neurological outcome, the levels of NSE in the CSF rose early (between 25 and 60 ng/ml) within 12 to 16 hours following the initial injury. The NSE levels then rapidly decreased to normal levels (~5 ng/ml) at approximately 20 hours following injury, with these levels persisting until day 5 (day of inal sample collection). Patients with a poor outcome (lack of ability to return to pre-injury activities or death) showed signiicantly higher levels of NSE persisting out to 5 days post injury, with late levels ranging from 35 to 50 ng/ml. Conclusions In TBI patients with a good outcome, there was an increase in NSE levels in the CSF noted at early time points (~16 hours), which abated at approximately 20 hours after injury. In TBI patients with a poor clinical outcome, CSF levels of NSE were signiicantly elevated at later time points over the irst 5 days post injury. P302 Hyperphosphorylated neuroilament NF-H, S100β and NSE as indicators of severity of brain injury in children J Žurek, L Marek, P Košut, M Fedora Faculty of Medicine, Masaryk University, University Children´s Hospital, Brno, Czech Republic Critical Care 2010, 14(Suppl 1):P302 (doi: 10.1186/cc8534) Introduction The aim of the study was to determine whether serum levels of biomarkers – hyperphosphorylated neuroilament NF-H, S100β protein and NSE – correlate with severity of brain injury and outcome in children with traumatic brain injury (TBI). Methods Thirty-eight patients with TBI were enrolled in the prospective study. TBI was veriied by computerized tomography according to S102 the Marshall classiication. Venous blood samples were taken after admission and every 24 hours for a maximum of 6 consecutive days. Serum NF-H concentrations were quantiied by ELISA, S100β and NSE by electrogenerated chemiluminescence. The outcome was evaluated 6 months after TBI using the Glasgow Outcome Scale (GOS) in all patients. Results Serum concentrations of NF-H (median 86 vs 12; P = 0.01), S100β (median 3.47 vs 0.54; P = 0.001), and NSE (median 193.2 vs 37.03; P = 0.001) were higher in nonsurvivors than survivors. Serum NF-H (median 86 vs 12; P = 0.004), S100β (median 3.47 vs 0.54; P = 0.001) and NSE (median 193.2 vs 37.03; P = 0.001) was signiicantly higher in patients with unfavourable outcome (GOS ≤3 vs GOS >3). Spearman’s rank correlation coeicient on irst day of hospitalization S100B x NSE = 0.58 (P <0.05), GCS x GOS = 0.50 (P <0.05), GOS x Marshall classiication = 0.46 (P <0.05). Conclusions Plasma levels of hyperphosphorylated neuroilament, S100β and NSE correlate with severity of TBI and may be useful as predictors of outcome in children with TBI. P303 A simple hospital discharge score predicts Glasgow Outcome Scale at 12 months in patients with traumatic brain injury GW Fuller, P Yeoman Queens Medical Centre, Nottingham, UK Critical Care 2010, 14(Suppl 1):P303 (doi: 10.1186/cc8535) Introduction This study examines whether a hospital discharge score predicts future Glasgow Outcome Scale (GOS) following traumatic brain injury (TBI). Loss to follow-up is a major problem in TBI studies and an early prediction score could be used for interpolation of missing outcome data or as a surrogate outcome measure. Methods Adults admitted to the Queens Medical Centre between 1993 and 2002 with TBI and GCS <12 were included prospectively in the Nottingham Head Injury Register. At hospital discharge the modiied Barthel Index was recorded by nursing staf and a Discharge Disability Score (DDS) calculated: 1. Independent, 2. Dependent <24 hour care, 3. Fully dependent, 4. Dead [1]. Glasgow Outcome Scale (GOS) was calculated at 12 months by the patient’s general practitioner [2]. Unfavourable outcome was deined as DDS 3, 4 or GOS 1, 2, 3. Correlation between DDS and GOS was measured and the ability of DDS to predict GOS at 12 months in survivors was assessed using logistic regression. Sensitivity and speciicity of dichotomised DDS for prediction of unfavourable outcome at 12 months was also calculated. Results Data were available on 1,227 patients. A highly correlated linear relationship was evident between DDS and GOS (spearman correlation coeicient 0.77, P <0.0001). Unfavourable outcome measured by DDS showed sensitivity of 73% (95% CI 69 to 76%) and speciicity of 56% (53 to 59%) for prediction of unfavourable outcome at 12 months deined by GOS. DDS showed a strong association with GOS at 12 months for survivors at discharge, with fully dependent patients having 15 times higher odds of an unfavourable outcome. Adjusting for known TBI prognostic factors attenuated the strength of the association, however DDS remained a statistically signiicant strong predictor of outcome. Conclusions DDS is strongly associated with 12-month GOS and could potentially be used to replace missing data or provide a surrogate outcome measure in TBI trials. A valid prediction score may also aid the clinician’s ability to discuss patient prognosis at hospital discharge. References 1. 2. Shah S, et al.: J Clin Epidemiol 1989, 42:703-709. Jennet B, et al.: Lancet 1975, 1:480-484. P304 Outcome of aggressive treatment for blunt and penetrating traumatic cardiac arrest Y Moriwaki, M Iwashita, Y Tahara, S Arata, N Harunari, T Kosuge, H Toyoda, N Suzuki Yokohama City University Medical Center, Yokohama, Japan Critical Care 2010, 14(Suppl 1):P304 (doi: 10.1186/cc8536) Introduction The outcome of patients with cardiac arrest due to blunt trauma (BT-CPA) and penetrating trauma (PT-CPA) is very poor. The aim of this study is to clarify the outcome of patients with CPA on arrival due Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 to BT-CPA and PT-CPA treated with our strategy including emergency department thoracotomy (EDT). Methods This study is a population-based case series observational study. We have taken three approaches to these patients: our private aggressive treatment strategy (resuscitation for 30 minutes, aggressive infusion using sheath introducer into the subclavian vein, and EDT); in-hospital system supporting this aggressive resuscitation (logistic issue such as the close location between ED and the room for catheter intervention and CT, and direct entrance to the OR by exclusive lift, and common instruments interchangeable between ED and OR including the bed); and prehospital EMS in our city (CPA patients are transferred in about 7 minutes to the nearest of selected 11 hospitals which can receive and treat CPA patients). Results For the past 10 years, of 478 BT-CPA and 30 PT-CPA patients, 76% and 70% were witnessed, and 21% and 37% were CPA after scene. A total of 85% and 77% underwent EDT. Although 34% and 60% achieved ROSC, only 18% and 40% went to the ICU, TAE room, and OR (admitted), and only 2.7% and 17% were discharged (survivors). Restricted in eight witnessed patients showing VF as the initial cardiac rhythm in BT-CPA, 38% were admitted and 13% survived. No PT-CPA patients showed VF. Restricted in 134 witnessed patients showing PEA in BT-CPA and 10 in PTCPA, 28% and 70% were admitted and 1% and 30% survived. Two hundred and twenty witnessed patients showing no life sign (asystole) in BT-CPA and 12 in PT-CPA, 8% and 25% were admitted, and 3% and 17% survived. The initial rhythm of survivors was asystole in 70% in BT-CPA and 40% in PT-CPA. Although the time interval from arrival at the hospital to ROSC of survivors tended to be shorter than for nonsurvivors in BT-CPA, there was no diference in this interval in PT-CPA. The longest interval was 43 and 30 minutes in BT-CPA and PT-CPA. Conclusions The expected outcome of BT-CPA and PT-CPA patients is hopeless. However, we cannot and should not give up on resuscitating them merely because they are CPA and they do not show any life sign at the scene. We consider the indication of aggressive resuscitation in every individual case by his/her individual condition. P305 Using low-rate limiting bag–valve–mask device without training J Nurmi1, M Castrén2 1 Helsinki University Central Hospital, Helsinki, Finland; 2Karolinska Institutet, Stockholm, Sweden Critical Care 2010, 14(Suppl 1):P305 (doi: 10.1186/cc8537) Introduction The Smart Bag (SB, O-Two Medical Technologies Inc., Canada) is a bag–valve–mask resuscitator (BVM) equipped with a valve limiting low-rate and peak airway pressure to decrease hyperventilation and gastric insulation. We studied this device used by hospital staf without training to evaluate the possibility to change the standard BVM to the SB in hospital wards where positive pressure ventilation is rarely needed and training is sporadic. S103 Methods The participants (12 physicians, 38 nurses) were randomised to use the standard BVM or SB to ventilate a resuscitation training manikin over 1 minute. The mechanism of the SB was shortly described in the SB group but no hands-on training was provided. Participants were asked to ventilate the patients as they would do if patients have a pulse but do not breathe. Tidal volumes were registered to a computer connected to the manikin. Results The medians of minute ventilation were 6.1 (interquartile range 2.6 to 8.1) and 3.9 (IQR 1.7 to 5.4) litres per minute in the SB and control groups, respectively (Figure 1). Hyperventilation >10 l/minute occurred only in the control group (P = 0.23). Conclusions Using the SB without previous hands-on training is possible for the majority of nursing and medical staf and decreases hyperventilation in comparison with the standard BVM. P306 Out-of-hospital cardiac arrest and resource utilisation in the ICU A Manning, M Purcell-Jones, A Saayman, M Wise University Hopsital of Wales, Cardif, UK Critical Care 2010, 14(Suppl 1):P306 (doi: 10.1186/cc8538) Introduction Survival rates for out-of-hospital cardiac arrests (OHCA) remain poor and typically of the order of 10% or less [1]. In the community, bystander CPR and public automated external deibrillators have been promoted, whilst in hospital therapeutic hypothermia and coronary reperfusion are employed to improve outcome. Few studies have assessed how this group of patients impacts on critical care resources [2]. Methods Patients with a spontaneous circulation following OHCA admitted to the critical care unit of a university teaching hospital between 1999 and 2009 were analysed retrospectively. Results A total of 1,656 patients presented to the emergency department following OHCA, of which 217 were admitted to the ICU. The ICU and hospital survivals were 41% and 32.7%, respectively. In the period 1999 to 2003, ICU and hospital survival rates were 37.5% and 22.9%, respectively. In the period 2004 to 2009, ICU and hospital survival rates were 43.8% and 40.5%, respectively. At admission to the ICU, the mean APACHE II score was 22.82, mean pH 6.87 and FIO2 52.6%. In those patients who survived hospital discharge, the mean APACHE II score was 19.71, mean pH 6.97 and FIO2 47.1%, whilst in nonsurvivors they were 24.33, 6.83 and 55.4%, respectively. Overall ICU and hospital lengths of stay (LOS) were 5.41 and 13.72 days and the average TISS score was 221. In those who survived to hospital discharge, ICU and hospital LOS were 10.1 and 32.4 days and the average TISS score was 380. Amongst patients who died in hospital, the mean ICU and hospital LOS were 3.1 and 4.7 days, the average TISS was 144. Conclusions Overall one-third of patients admitted to the ICU in the period 1999 to 2009 with OHCA were discharged from hospital. This increased to 40.5% in the period from 2004 with almost all patients discharged from the ICU surviving to hospital discharge. Nonsurvivors amongst the cohort are unsurprisingly more seriously ill with higher APACHE II scores and deranged physiology. The cost of treating survivors of OHCA in ICU is considerably higher for survivors compared with nonsurvivors. However, as patients who are discharged from ICU usually leave hospital (2004 to 2009), this would appear to be an appropriate utilisation of resources. References 1. 2. Sayre et al.: Prehosp Emerg Care 2009, 13:469-477. Graf J, et al.: Crit Care 2008, 12:R92. P307 Comparison of external cardiac compression on the loor and in a dental chair G Papakitsos, A Kapsali, T Papakitsou General Hospital Arta, Greece Critical Care 2010, 14(Suppl 1):P307 (doi: 10.1186/cc8539) Figure 1 (abstract P305). Minute ventilation (ml) in the Smart Bag group and the control group. Introduction Dental treatment is often stressful for patients and causes accidental systemic symptoms. In such situations, cardiopulmonary resuscitation (CPR) may be required. If external cardiac compression (ECC) in the dental chair is not efective, the patient should be moved onto the loor, which needs at least two or three persons and 10 to 15 seconds. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 In the current study, therefore, we investigated the eicacy of ECC in the dental chair in comparison with ECC on the loor. Methods Two dentists and two nurses with experience of ECC participated in this study; 30 ± 5 years old, 160 ± 5 cm in height, 65 ± 7 kg in weight. Before the study, they were educated about CPR and performed ECC for 5 minutes on the resuscitation manikin in two diferent situations; on the loor and in the dental chair. On separate days, they repeated these ECC procedures on the loor and in the dental chair again. The depth of compression and the percentage of adequate compression were evaluated. In addition, each participant commented on the preferable situation in the questionnaire after each set of ECC. Results Four dental personnel performed ECC ive times on the loor and ive times in the dental chair and commented on the preferable setting ive times. The eicacy of ECC was evaluated by the average depth and the percentage of ECC with adequate depth; 39.8 ± 8.2 mm and 46.8 ± 48.8% on the loor and 34.4 ± 6.9 mm and 41.7 ± 42.7% in the dental chair. The percentage of ECC with adequate depth was higher for the loor setting than that of the dental chair setting, although it did not reach statistical signiicance (P = 0.079). In the 20 questionnaires, three of them preferred the dental chair setting, two of them were no diference between both settings and 15 of them preferred the loor setting. Conclusions ECC on the loor can be performed efectively and easy and we can start CPR immediately after moving the patient onto the loor. Reference 1. Yokoyama T, et al.: Eicacy of external cardiac compression in a dental chair. Eur J Anaesthesiol 2008, 25(Suppl 44):2-5. P308 Efect of telephone CPR on the rate of bystander CPR for out-of-hospital cardiac arrest in a typical urban city in Japan Y Moriwaki, Y Tahara, H Toyoda, T Kosuge, M Iwashita, S Arata, M Toh, S Takagi, N Harunari, N Suzuki Yokohama City University Medical Center, Yokohama, Japan Critical Care 2010, 14(Suppl 1):P308 (doi: 10.1186/cc8540) Introduction Today, the emergency medical service (EMS) system has been developing in each country. However, it is not known whether people are willing to perform CPR and whether they are prepared to perform CPR under telephone CPR advice. In this study, we examined how Japanese citizens are interested in the importance of immediate CPR and deibrillation, and how they understand this importance. Methods Patients with out-of-hospital cardiac arrest due to nontraumatic etiology treated in our center for the past 2 years were enrolled. Cardiac arrest after the scene was excluded. Patients’ records from our emergency department were reviewed. In Japan, the ambulance service, dispatch service and emergency life-saving technician (ELST) belong to the ire Figure 1 (abstract P309). Efect of bystander CPR on the 1-month survival rate. S104 department. ELSTs perform not only advanced CPR for CPA patients on the job but also education of call takers in the central operation center under medical control about the importance of the recognition of CPA and advice for immediate bystander CPR. Results A total of 747 patients were enrolled. Telephone CPR advice was performed for bystanders of 336 (45%) patients and 304 bystanders actually performed CPR (90%). Five percent (40) of all 747 cases underwent voluntarily bystander CPR before telephone advice, 40% underwent bystander CPR according to telephone advice, and 4% (32) did not undergo CPR against telephone CPR advice. In 344 patients with bystander CPR, 33% reached ROSC, 11% survived more than 24 hours, and 3% were discharged, and in 391 patients without bystander CPR, 30%, 11%, and 6%, respectively. Restricted in 302 witnessed patients, of 125 with bystander CPR, 52% reached ROSC, 16% survived more than 24 hours, and 3% were discharged, and in 177 without bystander CPR, 44% reached ROSC, 14% survived more than 24 hours, and 1% were discharged, respectively. Conclusions Most people are willing to perform CPR. Bystanders are prepared to perform CPR with telephone CPR advice to help them. However, bystander CPR is not always adequate, resulting in no distinct efect of CPR on survival rate. We should educate citizens beforehand and guide bystanders with more proper and quick advice by telephone. P309 Time factors rather than type and/or nature of CPR modify the prognosis of out-of-hospital cardiac arrests witnessed by bystanders H Inaba, T Yachida, M Enami, Y Takei, Y Goto, K Ohta Kanazawa University Graduate School of Medicine, Kanazawa, Japan Critical Care 2010, 14(Suppl 1):P309 (doi: 10.1186/cc8541) Introduction The purpose of the study was to analyze the efects of the type and nature of CPR on the prognosis of out-of-hospital cardiac arrests (OHCAs). Methods We analyzed 1,612 OHCAs, witnessed by citizens and handled by the dispatch system in Ishikawa, Japan, from 1 April 2003 to 31 March 2008. Bystander CPR was classiied into four groups according to type (CC only or CC + MMV) and nature (under one’s own initiative or telephoneassisted instruction). Results The presence of bystander CPR signiicantly augmented the 1-month survival rate. However, there were no signiicant diferences among the four groups of CPR. The multivariate logistic regression analysis identiied three time factors including intervals of collapse-to-call, call-toirst CPR, call-to-arrival to patients as independent factors associated with 1-month survival. See Figures 1 and 2. Conclusions Signiicance of correctable time factors rather than type of CPR should be considered in the future guideline revision. Figure 2 (abstract P309). Factors associated with 1-month survival Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P310 Use of the laryngeal tube by paramedics during prehospital resuscitation: an observational study G Papakitsos1, T Papakitsou2, A Kapsali1 1 General Hospital Arta, Greece; 2General Hospital Messologi, Greece Critical Care 2010, 14(Suppl 1):P310 (doi: 10.1186/cc8542) Introduction In the current guidelines of the ERC, tracheal intubation has become less important for persons not trained and diferent supraglottic airway devices are recommended. The present investigation deals with the application of the laryngeal tube (LT) during prehospital resuscitation by paramedics. Methods The study was observational during a period of 2 years (2007 to 2009). We registered all cardiac arrest situations in which the LT had been applied according to the ERC guidelines 2005. All participants had completed an obligatory course in emergency medicine, but had not been speciically trained in endotracheal intubation; they were therefore designated as unfamiliar in using the endotracheal tube to secure the airway. Primary outcome measures were placement time and successful placement. Study endpoint was the total ‘no low time’, which is deined as the time without chest compression in the irst period of cardiac arrest. Results During the deined period, 53 resuscitation attempts recorded on standardised data sheets were included. The LT was used in 87% of all cardiac arrest situations. Overall, the LT was successfully and signiicantly faster inserted (about 9.4 seconds) in more than 96% of all cases, on the irst attempt. In 99% of all cases, no problems concerning ventilation of the patient were described. During the cardiac arrest simulation, establishing and performing irst ventilation took an average of 12.5 seconds with the LT. Use of the LT during cardiac arrest signiicantly reduced the ‘no low time’ about 87.6 seconds. Conclusions As an alternative airway device recommended by the ERC, the LT may enable airway control rapidly and efectively. Additionally, by using the LT, a reduced ‘no-low-time’ and a better outcome may be possible. LT may be a good alternative airway device for providing and maintaining a patent airway during resuscitation. Reference 1. Wiese CH, et al.: The use of the laryngeal tube disposable (LT-D) by paramedics during out-of-hospital resuscitation-an observational study concerning ERC guidelines 2005. Resuscitation 2009, 80:194-198. S105 comparing the PM with the DR, the PM required 16.5 seconds for the cLMA (vs 16.9 seconds, P = 0.693), 14.9 seconds for the LM (vs 16.8 seconds, P = 0.08) and 7.8 seconds for the i-gel (vs 9.4 seconds, P = 0.001). The total time needed for secondary ET was on average 25.8 seconds (PM 24.2 seconds, DR 27.9 seconds, P <0.001). Error-free insertion at all ive incidents was achieved by 73.3% of DR and by 46.1% of PM (P <0.001). Conclusions Suicient ventilation was achieved 50% faster through the i-gel when compared with the cLMA and the LT. The correct usage of the i-gel can be learnt quickly. The i-gel allows the options of secondary ET. Reference 1. Emmerich M: Use of the i-gel laryngeal mask for management of a diicult airway. Anaesthetist 2008, 57:779-781. P312 Retention of skills during emergency airway management training: a 12-month follow-up H Fischer1, A Fast1, E Kajcsa1, M Fleck1, R Greif2 1 General Hospital Vienna, Austria; 2University Hospital Bern, Switzerland Critical Care 2010, 14(Suppl 1):P312 (doi: 10.1186/cc8544) Introduction Besides the gold standard endotracheal tube, supraglottic airway devices are alternatives for emergency airway management [1]. The goal of the study was to identify airway devices that provide successful ventilation, even 12 months after training in manikins. Methods In 2008, 288 medical students were trained to use laryngeal mask airways (LMAs) Unique, ProSeal, Supreme, I-Gel and bag–mask ventilation (BM) on manikins (Ambu). Students successful on the irst attempt (n = 190) for all devices in random order were included and tested 12 months later without further training. The insertion time to irst successful ventilation, tidal volume (TV) and gastric inlation were assessed. Results The time (in seconds) needed for the I-Gel and the Unique was signiicant longer in 2009 (BM 2008 8.2 ± 4.7 vs 2009 8.4 ± 5.4, P = 0.882; I-Gel 2008 10.2 ± 2.7 vs 2009 11.7 ± 4.9; P = 0.008; Supreme 2008 15 ± 3.7 vs 2009 15.5 ± 4.6, P = 0.147; Unique 2008 16.5 ± 3.6 vs 2009 18.2 ± 5.5; P = <0.001; ProSeal 2008 17.7 ± 4.9 vs 2009 17.7 ± 5.2, P = 0.856). A higher rate of gastric inlation for BM and the I-Gel was seen in comparison of 2008 with 2009 (BM 10.5% vs 18.6%, P = 0.012; I-Gel 0.5% vs 4.2%, P = 0.039; Supreme 0.5% vs 2.2%, P = 0.375; Unique 3.7% vs 5.8%, P = 0.607; ProSeal 4.7% vs 1.2%, P = 0,18). About 60% of the TVs were insuicient with little improvement for the Supreme and Proseal (Figure 1). P311 The i-gel supraglottic airway as an alternative in the preclinical emergency medical aid? A comparative study on a manikin J Tiesmeier, M Emmerich Krankenhaus Bad Oeynhausen, Germany Critical Care 2010, 14(Suppl 1):P311 (doi: 10.1186/cc8543) Introduction Endotracheal intubation (ET) is the recognised gold standard for securing an airway in the realm of preclinical emergency medical aid. Supraglottic airway devices present a valid alternative in the case of an elevated incidence of diicult airway securing and intubation preconditions. Due to positive experiences with the i-gel supraglottic airway, we – through a joint paramedic (PM) and doctor (DR) team – have compared its use under standardised conditions with the classic laryngeal mask (cLMA) and the laryngeal tube (LT) using an airway simulator. Methods Seventy-one probands (40 PM and 31 DR) took part in this study. The airway simulator used was the Ambu® Airway Man. Timekeeping started with the laying aside of the anaesthesia bag after successful ventilation of the airway simulator and ended after having ensured suicient ventilation. Participants used three diferent devices (i-gel size 4, cLMA size 3 and LT size 4) each ive times. Additionally, an interval time was measured after successful ventilation with the i-gel. Without interruption, participants continued the experiment with two interval ventilations and conducted a secondary ET through the i-gel. Timekeeping ended in this case after the irst ventilation. Results Prior to the study 95% of PM had previous experience with the cLMA, 77.5% with the LT and 0% with the i-gel. Respective percentages for DR were 61.2% for the cLMA, 38.7% for the LT and 32.2% for the i-gel (P <0.001 respectively). Across the entire group of 71 study participants, users required an average of 16.6 seconds for the successful insertion of the cLMA, 15 seconds for the LT and 8.48 seconds for the i-gel. When Figure 1 (abstract P312). Tidal volume (correct range 0.4 to 0.6 l). Conclusions One year after training, time for successful ventilation for all devices was lower than 25 seconds. This is acceptable compared with the gold standard endotracheal tube, but due to the rising gastric inlation rate and high amount of insuicient tidal volume, shorter intervals of training maybe necessary. References 1. Nolan JP, et al.: Resuscitation 2005, 67(Suppl 1):S54-S56. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S106 P313 Factors correlated with the advanced life support simulation performance of senior medical students KH Park, YJ Kang Jeju National University Hospital, Jeju-si, Republic of Korea Critical Care 2010, 14(Suppl 1):P313 (doi: 10.1186/cc8545) Introduction Even though medical education using simulation for medical students is increasing and suggests positive outcomes, little is known about factors associated with the performance of advanced life support simulation. We investigated the correlation between various factors and simulation performance using senior medical students. Methods Fourth-year medical students were enrolled and divided into six groups. Each group underwent a 2-week emergency medicine training. This study was conducted consecutively with a 2-week break between each group from March to July, 2009. Every student had an advanced cardiac life support (ACLS) simulation performance test as a moderator, scored by two ACLS instructors certiied by the American Heart Association. The following data were examined: basic life support (BLS) practice, personality characteristics survey, case presentation, one posttraining written test, and two plan tests for the Korean Medical Licensing Examination (KMLE). The statistical signiicance was deined as P <0.05. Results Forty-six students participated. No correlation was found between ACLS performance scores and personality type or medical knowledge as measured by the post-training written test and the two plan tests for the KMLE. However, scores of the BLS examination and the case presentation were moderately correlated with the ACLS performance scores: r = 0.390, 0.402, respectively (P <0.01). Conclusions The ACLS simulation performance was correlated with the BLS skills and the case presentation. This supports the idea that the ability to manage resuscitation is associated with BLS skills and the capability to analyze and coordinate patient management. This result provides guidance for education of medical students. P314 Aging augments unwllingness to the initial three links in chains of survival H Inaba, M Enami, T Yachida, Y Takei, O Oyama, K Ohta Kanazawa University Graduate School of Medicine, Kanazawa, Japan Critical Care 2010, 14(Suppl 1):P314 (doi: 10.1186/cc8546) Introduction The purpose of the study was to clarify the inluence of aging on attitudes toward the initial three links in chains of survival. Methods We gave questionnaires to attendants of compulsory programs for basic life support (BLS) or driving technique at the beginning in authorized driving schools. The questionnaires included their backgrounds. We studied their willingness in four hypothetical scenarios related to the initial three links: early emergency call, cardiopulmonary resuscitation (CPR) under one’s own initiative, telephone-assisted chest compression and use of AED. The respondents were divided into young (17 to 29 years, n = 6,122), middle-aged (29 to 59 years, n = 827), older person (>59 years, n = 15,743) groups. Results There were signiicant diferences in gender, occupation, residential area and experience of BLS training, and knowledge of AED use between the three groups. The proportions of respondents who are willing to perform the desirable BLS actions were lowest in the older person group (Table 1). Multiple logistic regression analysis conirmed that aging is one of the independent factors relating to negative attitude in all the scenarios. Gender, occupation, resident area, experience of BLS training, and knowledge for AED use were other independent factors relating to negative attitude to some of the scenarios. Conclusions The aged population is more negative to the chain of survival. More are willing to follow the telephone-assisted direction for chest compression. The BLS training should be modiied for them to gain conidence and to be aware of the signiicance and beneit of early call. P315 Prediction of the success of cardiac resuscitation: a pattern classiication approach based on ECG spectral and temporal features M Baronio1, F Baronio2, M Campi2, G Amicucci1, A Caré2, A Sorgato3, G Perone4, A Candiani4 1 Ospedale S. Orsola Brescia, Italy; 2Department of Information Engineering, University of Brescia, Italy; 3Division of Cardiology, Ospedale S. Orsola, Brescia, Italy; 4Spedali Civili, University of Brescia, Italy Critical Care 2010, 14(Suppl 1):P315 (doi: 10.1186/cc8547) Introduction The ECG tracings recorded during a ventricular ibrillation (VF) using an automated external deibrillator (AED) contain useful information predictive of shock outcome. The focus is on the VF waveforms’ morphology. The amplitude and the spectral properties of VF may predict the likelihood of successful deibrillation [1-4]. In almost all previous studies, the amplitude or the spectral properties of the ECG tracings have been singularly used. However, these approaches have led to methods lacking suicient predictive power. Methods Five hundred patients with out-of-hospital cardiac arrest on arrival in an emergency room were examined. The rhythm was identiied as VF and conirmed by two trained investigators. ECG data were stored in modules in digitized form over a period of 20 minutes and were analyzed retrospectively. ECG traces containing CPR artefacts were removed by digital iltering. Times of collapse, dispatch, scene arrival, CPR, and initial deibrillation were determined from dispatch records, recordings of arrest events, interviews with bystanders, and hospital records. The preshock VF waveform morphology was studied and diferent parameters of VF ECG signals were extracted. We then introduced a pattern classiication machine that combines the amplitude and spectral features simultaneously. Results The use of the pattern classiication machine which combines amplitude and spectral features of VF ECG signals shows an improved predictive power as compared with other methods. Conclusions This technique could help to determine which patients should receive shock irst and which should receive a period of CPR prior to shock, thereby increasing the probability of survival. The potential impact of this research is high in the direction of generating a new methodology able to increase the probability of survival after a cardiac crisis. References 1. 2. 3. 4. Strohmenger H: Chest 1997, 111:584-589. Sherman LD: Resuscitation 2006, 69:479-486. Hamprecht F: Resuscitation 2001, 50:297-299. Eftestol T: Resuscitation 2005, 67:55-61. Table 1 (abstract P314). Diference among the three age groups in the proportion of respondents who are willing to perform the desirable BLS actions Age group Scenario 17 to 29 years 29 to 59 years >59 years Chi-square test P value CPR under their own initiative 78.9% (4,810/6,094) 71.9% (589/819) 57.1% (8,186/14,346) <0.001 Telephone-assisted chest compression 94.6% (5,766/6,898) 92.5% (757/818) 84.6% (12,112/14,316) <0.001 Early 119 call 91.2% (5,556/6,092) 91.2% (747/819) 79.4% (12,130/15,270) <0.001 Use of AED 56.8% (3,386/5,963) 48.4% (388/801) 21.4% (2,832/13,285) <0.001 Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P316 Dispatcher-assisted telephone cardiopulmonary resuscitation using a French compression-only protocol: performance of volunteers with or without prior life support training A Ghuysen1, S Stipulante2, D Colas1, V D’Orio1 1 CHU Liège – ULG, Liège, Belgium; 2CS 100 Liège, Belgium Critical Care 2010, 14(Suppl 1):P316 (doi: 10.1186/cc8548) Introduction Although early bystander-initiated cardiopulmonary resuscitation (CPR) is a key factor in survival improvement from out-ofhospital cardiac arrest, only one-third of victims actually receive CPR before arrival of emergency medical services. Dispatcher-assisted telephone CPR might improve the frequency and performance of bystanders’ resuscitation eforts. Due to the recent interest in hands-only CPR protocol [1] and the lack of any French validated algorithm, we designed the present study in order to validate a new French protocol called ALERT (Algorithme Liègeois d’Encadrement à la Réanimation par Téléphone). Methods We tested the eicacy of the ALERT protocol on CPR performances in a manikin model of cardiac arrest. Participants (n = 110) were divided into four groups. Previously untrained subjects, distributed into two sub-groups depending on whether they were beneiciating from telephone assistance (PUG group, n = 30) or not (PUNG group, n = 30), were compared with previously trained nurses students distributed in two other sub-groups: with (PTG group, n = 25) or without (PTNG group, n = 25) telephone assistance. Results Global evaluation of CPR performances in untrained volunteers beneiting from telephone assistance revealed a signiicant improvement as compared with unguided untrained volunteers. Indeed, they approached CPR performance levels of previously trained nurse students with no dispatcher’s guidance. Previously trained nurses with telephone assistance gained the best CPR scores, notably because of an improvement in the quality of airway management. Conclusions Our results indicate that use of the ALERT algorithm by dispatchers may improve the CPR performance in both previously untrained volunteers and in volunteers with prior basic life support training. Reference 1. Hallstrom AH, et al.: N Engl J Med 2000, 342:1546-1553. P317 CPR team members’ attitudes towards family presence during cardiopulmonary resuscitation N Kianmehr, M Moidi, H Rahmani, A Forouzan Iran University of Medical Sciences, Tehran, Iran Critical Care 2010, 14(Suppl 1):P317 (doi: 10.1186/cc8549) Introduction The concerns about allowing family members to be present during resuscitation are a matter of debate in many countries. The purpose of this study was to determine the opinions of Iranian health-care providers about family-witnessed resuscitations. Methods The study population consisted of CPR team members in four teaching hospitals. We developed a questionnaire, assessing their opinions, using 20 questions and also considering their comments. Results Of the total 200 participants, 77% oppose family-witnessed resuscitation. There was no signiicant diference among opponents about FWR based on sex, age, number of CPR exposures and the experience of respondents (P >0.05). Emergency physicians were more likely advocates for FWR than other specialties (P = 0.004). All of the anesthesiologists opposed FWR. Most reasons for opposition were fear of psychological trauma to family members, interference with patient care, increased staf stress and violation with patient conidentiality. Conclusions CPR team members in Iran do not believe in the presence of relatives during resuscitation. Informing healthcare providers on the beneit of witnessed resuscitation and public education of CPR would be a fundamental element for implementing a formal program. References 1. 2. 3. Bae H, Lee S, Jang HY: The ethical attitude of emergency physicians toward resuscitation in Korea. J Emerg Med 2008, 34:485-490. Maclean SL, Guzzetta CE, White C et al.: Family presence during cardiopulmonary resuscitation and invasive procedures: practices of critical care and emergency nurses. J Emerg Nurs 2003, 29:208-221. Tucker TL: Family presence during resuscitation. Crit Care Nurs Clin North Am 2002, 14:177-185. S107 P318 Prehospital therapeutic hypothermia induced with cold infusions improves haemodynamic stability in nonshockable cardiac arrest patients A Truhlar1, R Skulec2, J Seblova2, L Zabka3, V Cerny1 1 University Hospital, Hradec Kralove, Czech Republic; 2Central Bohemian Region EMS, Kladno, Czech Republic; 3Hradec Kralove Region EMS, Hradec Kralove, Czech Republic Critical Care 2010, 14(Suppl 1):P318 (doi: 10.1186/cc8550) Introduction Recent studies report an increase of asystole and pulseless electrical activity (PEA) as the irst monitored cardiac arrest rhythms after arrival of the Emergency Medical Services [1]. The asystolic patients presumably undergo ischaemia for a longer time and may beneit from treatment reducing hypoxic brain injury. Therapeutic hypothermia (TH) has expanded into prehospital care to be initiated as soon as possible. Rapid cold crystalloid infusion is the most frequent method; however, severe haemodynamic instability is its contraindication. The aim of the study was to assess the adverse efects of prehospital volume expansion in patients with initial nonshockable rhythms when used in a setting with only restricted cardiovascular monitoring. Methods The nonshockable patients enrolled in a prospective nonrandomized PRE-COOL trial (PRE-hospital COOLing in cardiac arrest patients) were rapidly administered cold normal saline (5 to 30 ml/kg) intravenously and analysed for body temperature, haemodynamic variables (blood pressure, heart rate, shock index), incidence of circulatory complications (recurrence of cardiac arrest, pulmonary oedema), and outcome. Hypothermic patients (group A, n = 19) were compared with matched historic controls (group B, n = 22). Results In treatment group A, 1,021 ± 526 ml (13.2 ± 6.3 ml/kg) of 4°C cold normal saline was administered before hospital admission. Body temperature decreased by 1.32 ± 0.71°C until arrival at hospital (calculated rate 1.08 ± 0.44°C/30 minutes). The incidence of hypotension requiring vasopressors (noradrenaline or dopamine) signiicantly decreased in patients given cold intravenous luids compared with control group B: 31.6% vs 63.6% (P = 0.04). No patient developed pulmonary oedema within 24 hours. Recurrence of cardiac arrest was comparable in both groups (3/19 vs 3/22), shock index at hospital arrival was 0.92 vs 0.97 (P = 0.78), and favorable outcome (cerebral performance category 1 or 2) 26.3% vs 13.6% (P = 0.31). Conclusions The early prehospital administration of cold infusions is safe and contributes to haemodynamic optimization in patients resuscitated from nonshockable rhythms. Incidence of hypotension requiring vasopressors was signiicantly reduced in the treated group. No pulmonary oedema was observed. Acknowledgements Supported by grant IGA MH CZ NS10383-2/2009 and research project MZO 00179906. Reference 1. Hallstrom A, et al.: Resuscitation 2009, 80:975-976. P319 Trans-nasal cooling during CPR: a single-center experience FS Taccone, JL Vincent Erasme Hospital, Brussels, Belgium Critical Care 2010, 14(Suppl 1):P319 (doi: 10.1186/cc8551) Introduction Trans-nasal cooling started during cardiopulmonary resuscitation (CPR) has shown to improve the return to spontaneous circulation (ROSC) and survival rate in an experimental prolonged cardiac arrest model. A multicenter randomized trial (PRINCE) has also suggested an improved neurological outcome in patients receiving trans-nasal cooling during CPR in the prehospital setting when compared with those treated by conventional hypothermia on hospital arrival, provided a delay between collapse and CPR of less than 10 minutes. Methods Patients with witnessed cardiac arrest and a downtime less than 20 minutes were randomized to prehospital intra-arrest cooling versus standard ACLS care. Trans-nasal cooling (RhinoChill, BeneChill Inc., CA, USA) was initiated using a mixture of volatile coolant luid with oxygen delivered into the nasopharynx for rapid evaporative heat transfer. Cooling was continued during CPR and, for patients who achieved ROSC, until initiation of systemic cooling at hospital. Resuscitation was continued for at least 30 minutes. All patients were then cooled at the hospital. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S108 Results Twenty-four patients were included, but one in the treatment group was excluded from the per-protocol analysis because of DNR orders. Patients randomized to treatment group (n = 9) or standard care (n = 14) had similar demographics, initial rhythm, time from collapse to CPR and ALS arrival. Median time from collapse to cooling initiation was 19 minutes. In total, 6/9 (66%) treated and 6/14 (42%) control patients achieved ROSC. Three patients (33%) in the treatment group survived to hospital discharge with CPC 1 to 2, while only one (7%) of the control group patients had good neurological outcome. No serious adverse events occurred in treated patients. Conclusions Trans-nasal cooling seems to be safe and feasible in a prehospital setting. These single-center data conirm that trans-nasal cooling may improve the ROSC rate as well as good neurological outcome if started in patients with a short delay between collapse and CPR. P320 Intra-arrest cooling using a novel intra-nasal cooling method for immediate induction of therapeutic hypothermia in Germany H Busch1, H Fritz2, F Eichwede3, B Inderbitzen4, D Barbut4, T Schwab1 1 Intensive Care Unit Heilmeyer, Freiburg, Germany; 2Krankenhaus MarthaMaria Halle-Dölau, Halle/Saale, Germany; 3Medizinisches Zentrum Aachen, Würselen, Germany; 4Benechill, San Diego, CA, USA Critical Care 2010, 14(Suppl 1):P320 (doi: 10.1186/cc8552) Introduction Recent investigations have demonstrated improved neurological outcome after therapeutic hypothermia in patients after successful resuscitation. The time course and duration to achieve target temperature may be an important factor to inluence patient’s outcome. To determine the safety and eicacy of intranasal cooling during ongoing resuscitation, for immediate induction of therapeutic hypothermia, the Pre-Resuscitation Intra-Nasal Cooling Efectiveness (PRINCE) study involved 200 patients in Europe, using a non-invasive nasal catheter that sprays evaporating coolant liquid into the nasal cavity. Here we demonstrate data from all German participating sites. Methods All patients who were deemed eligible for advance cardiac life support (ACLS) were included as long as the arrest was witnessed and cardiopulmonary resuscitation (CPR) was initiated within 20 minutes of collapse. Patients were randomized to treatment or control groups. The trial was designed to determine the safety and efectiveness of early cooling initiated at the site of arrest. Survival and time to target temperature were documented. Results Data are presented as the mean ± SD or median (interquartile range (25, 75%)). Mean age was 67.8 ± 14 years in the intervention group and 65.4 ± 13.9 years in the control group. On average, cooling therapy was started in 33 ± 12 minutes in the RhinoChill™ group and 170 ± 97 minutes in the control group. Temperatures at hospital admission were signiicant lower in the RhinoChill™ group. Time to target tympanic temperature, relecting brain temperature, were signiicant faster in the RhinoChill™ group (211 ± 124 minutes vs 424 ± 217 minutes; P <0.05). Adverse events occurred in 12 patients. None was related to the cooling therapy. In the intervention group ive patients (20%) survived and three patients (12%) had a CPC of 1 to 2. In the control group only four patients (12.5%) survived and one patient (3.1%) had a CPC of 1 to 2. Conclusions Using the intranasal cooling method, cooling was much faster and earlier in treated patients. Neurologically intact survival and discharge rates were higher in treated patients. Transnasal cooling for the induction of therapeutic hypothermia during prehospital resuscitation is feasible and highly efective in lowering brain temperature rapidly. The method ofers the possibility for immediate introduction and realization of mild hypothermia in the ield. P321 Therapeutic hypothermia after cardiac arrest: implementation in UK intensive care units A Binks1, R Murphy1, A Padkin2, J Nolan2 1 Bristol Royal Inirmary, Bristol, UK; 2Royal United Hospital, Bath, UK Critical Care 2010, 14(Suppl 1):P321 (doi: 10.1186/cc8553) Introduction In 2003 the International Liaison Committee on Resuscitation (ILCOR) published guidelines recommending all patients admitted Figure 1 (abstract P321). Implementation of therapeutic hypothermia in UK ICUs by year. comatose to hospital following an out-of-hospital cardiac arrest (OHCA) with an initial rhythm of ventricular ibrillation should be treated with therapeutic hypothermia for a period of 12 to 24 hours [1]. We aimed to determine how many units are using hypothermia as part of their postcardiac arrest management and when each of the ICUs implemented the therapy. Other objectives were to determine what cooling techniques are being used, the target temperature and the duration of cooling used. Methods The 248 UK ICUs listed in the Directory of Critical Care Services were contacted by telephone by one of the authors. The duty ICU consultant or nurse in charge was asked a standardised set of questions. Results We obtained responses from 244 of 248 (98.3%) of ICUs. Currently, 209 (85.6%) ICUs are using hypothermia as part of post-cardiac arrest management. Since 2003, there has been an increase annually in the number of units using hypothermia, with the majority of units starting in 2007 or 2008 (Figure 1). Of the units who use hypothermia as part of their post-cardiac arrest management, 99% are using it to treat patients after OHCA from shockable rhythms, 60.6% are using it to treat patients after OHCA from nonshockable rhythms, and 63.5% are using it after in-hospital cardiac arrest. Cooling is initiated with intravenous cold luid in 71%. The commonest technique to maintain hypothermia is to use ice; used by 55% of units. Most ICUs (89.9%) aim for a temperature of 32 to 34°C and the duration of hypothermia is 24 hours in 141 ICUs (67.5%). Conclusions Generalised implementation of this clinical guideline in the UK has taken about 5 years but now the majority of ICUs are using therapeutic hypothermia as part of post-cardiac arrest management. Reference 1. Nolan J: Circulation 2003, 108:118-121. P322 Hospital-wide therapeutic hypothermia protocol signiicantly reduces the time to induce hypothermia but does not improve outcomes P Hayden, AA James Medway NHS Foundation Trust, Gillingham, UK Critical Care 2010, 14(Suppl 1):P322 (doi: 10.1186/cc8554) Introduction Therapeutic hypothermia (TH) is a reliable, evidence-based modality to improve neurological outcome following out-of-hospital cardiac arrest. Often TH is induced in the ICU and as a result the time from cardiac arrest (CA) to induction of TH (THst) and achieving target temperature (CAta) is delayed. Preliminary data have shown that delaying TH may worsen outcome [1]. We sought to investigate whether a hospitalwide approach to TH after CA would reduce delays and result in improved outcomes. Methods We conducted a retrospective analysis of all TH interventions from 2007 to 2008. Following this we implemented a hospital-wide approach to TH and re-evaluated in 2008 to 2009. The hospital-wide approach included an educational programme, TH guidelines in the resuscitation room in the ED, and a cooling pack stored in the ICU which could be taken immediately to the post-CA patient. Results CA-ROSC and CA-Hosp delays were similar between groups. The hospital-wide approach signiicantly reduced the time to initiate TH and time to achieve target temperature (see Table 1). The small sample size may have prohibited demonstration of outcome diferences. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S109 Table 1 (abstract P322). Diferences between groups pre and post the hospital-wide approach 2007 to 2008 2008 to 2009 16 26 CA-ROSC 28.5 minutes 24.1 minutes CA-Hosp 59.1 minutes 50.1 minutes n P value CA-THst 306.2 minutes 133.2 minutes <0.0001 CA-THta 527.3 minutes 252.7 minutes 0.005 7 13 0.69 HospSurv Conclusions A hospital-wide approach to TH following cardiac arrest signiicantly reduces delays to achieve the target temperature, although this did not improve outcomes at our institution. Initiation of prehospital TH may be an ideal solution to further reduce this delay, and ongoing trials may demonstrate improved outcomes. Reference 1. Nozari A, et al.: Critical time window for intra-arrest cooling in a dog model. Circulation 2006, 113:2690-2696. P323 Induced hypothermia after cardiac arrest for 12 hours: single-centre experience R Sykora1, R Janda2 1 Charles University, Medical School and Teaching Hospital, Plzen, Czech Republic; 2Hospital of Karlovy Vary, Czech Republic Critical Care 2010, 14(Suppl 1):P323 (doi: 10.1186/cc8555) Introduction Induced hypothermia (IH) for 12 to 24 hours is a standard part of post-resuscitation care. We present a cohort of patients with outof-hospital or in-hospital cardiac arrest (OHCA, IHCA) from our ICU who underwent 12 to 14 hours of IH. Moreover we aimed at neurological outcome in a subgroup of patients with initial ventricular ibrillation (VF) and ST-elevation acute myocardial infarction (STEMI) undergoing coronary intervention (PCI). Methods We retrospectively evaluated patients with nontraumatic cardiac arrest admitted to our ICU from 2006 to 2009. A standardised therapeutic protocol including IH was implemented. IH (32 to 34°C) was started within 30 minutes after restoration of spontaneous circulation (ROSC), before PCI, if performed. IH was maintained for 12 to 14 hours, than passive rewarming followed. Endovascular cooling device was not used. Cerebral performance category (CPC) at hospital discharge was evaluated as a main outcome. Results Total number of patients was 88 (OHCA n = 63; IHCA n = 25), mean age 57 years, 65% men. ICU mortality was 32% and hospital mortality 53%. Initial ECG rhythm was VF in 59%, asystole in 32% and pulseless electrical activity in 9%. Coronary angiography was performed in 59% and intervention in 41% of all cases. The required target temperature was achieved in 76%. Complications were ventilator-associated pneumonia in 6%, tracheobronchitis in 15% and gastrointestinal bleeding in 2%, no severe bradyarhythmias or iontogram dysbalance was recorded. In a group of 23 patients with VF/STEMI, PCI after initiation of IH was performed. The required target temperature was achieved in 91%. The ICU survival rate was 87% and survival to discharge from hospital was 78%. Good neurological outcome (CPC 1 or 2) in this group at hospital discharge was in 83% (n = 15). Conclusions Induced hypothermia has to be started as soon as possible after ROSC. Cooling of patients after cardiac arrest should continue during all therapeutic interventions. Twelve hours of induced hypothermia after cardiac arrest could ofer comparable neurological outcomes to 24 hours, especially in the subgroup of patients with VF/STEMI. Acknowledgements Supported by a research project MSM 0021620819. P324 Survival following adult cardiac arrest in intensive care units: a 5-year retrospective analysis S Bagshaw, P Brindley, D Kutsogiannis University of Alberta Hospital, Edmonton, Canada Critical Care 2010, 14(Suppl 1):P324 (doi: 10.1186/cc8556) Introduction This study aims to provide survival data for adult patients following attempted cardiopulmonary resuscitation (CPR) in critical care units. We hope objective data can facilitate dialogue and decision-making. Methods We retrospectively reviewed CPR records from 1 January 1 2000 to 30 April 2005 from all critical care units of the tertiary care hospitals of Edmonton, Canada. Full inpatient medical records were reviewed for further details. Results Of 529 arrests, 59.4% had return of spontaneous circulation, 29.5% survived to critical care unit discharge, 26.3% survived to hospital discharge, 20.5% survived to 3 months, and 19.9% to 6 months. Pulseless electrical activity (PEA) represented 29.7%, ventricular tachycardia (VT) 20.8%, asystole (ASY) 15.7%, bradycardia 15.5%, ventricular ibrillation (VF) 13.4%, supraventricular tachycardia 2.8%, and respiratory arrest 2.1%. A total 36.7% of arrests occurred between 08:01 and 16:00 hours, 33.0% occurred between 00:01 and 08:00 hours and 30.3% between 16:01 and 24:00 hours. There was no signiicant association between arrest time and survival. There was a signiicant association between longer CPR duration and increased mortality (P <0.001). GSICU cardiac arrest patients had statistically higher critical care unit mortality than CCU or CVICU patients (75.5% vs 70.0% vs 45.7%; P = 0.002). ASY/PEA were signiicantly more common in GSICUs, whereas VF and VT were more common in CVICU (P = 0.001). Mortality was signiicantly higher following PEA/ASY regardless of location. Multivariate analysis showed no signiicant association between survival and age, gender or arrest time. In contrast, survival was signiicantly lower with increased APACHE II score (O.R 1.07, P <0.001), prolonged CPR (O.R.1.03, P <0.01), and ASY/PEA (O.R. 5.44, P <0.001). No patient with an APACHE II ≥30 survived to hospital discharge following PEA.ASY, and no patient, regardless of arrest type, survived to hospital discharge with an APACHE II >45. Conclusions Initial survival following in-hospital cardiac arrest is higher than from noncritical care units, and therefore should be considered diferently. Survival was higher still from cardiac ICUs compared with other critical care units. Admission APACHE II, type of arrest, and resuscitation duration provide useful prognosticators, especially in combination. In contrast, age, gender, and arrest time do not. Despite encouraging early survival, less than one-quarter survived to hospital discharge, and less than one-in-six were alive at 1 year. P325 Efects of bed height and time on the quality of chest compressions during cardiopulmonary resuscitation A Lewinsohn, PB Sherren, DS Wijayatilake Queens Hospital, London, UK Critical Care 2010, 14(Suppl 1):P325 (doi: 10.1186/cc8557) Introduction The 2005 International Liaison Committee on Resuscitation gave a detailed update on best practice for CPR with a discussion around appropriate patient and rescuer position, based largely on expert opinion [1]. The objectives of this study were: to demonstrate a diference in chest compression efectiveness with bed height, and provide a suggestion for an optimal and achievable bed height for efective chest compressions; and to demonstrate fatigue during chest compressions, and provide a suggestion for an upper time limit for efective chest compressions. Methods Exclusion criterion for this trial; no previous basic life support training in the past 4 years, or refused consent to participate. A modiied Laerdal manikin was connected to a Dragor ventilator (to measure intrathoracic pressures generated). The manikin was placed on a hospital trolley, and CPR was performed by candidates at three diferent bed heights: mid thigh; anterior superior iliac spine; and xiphisternal area. Chest compressions were continuous and asynchronous with ventilation, and allowed to continue for 30 seconds before recordings were taken. Results One hundred and one subjects took part. The diferences in intrathoracic pressures generated at diferent bed heights were compared using ANOVA variance testing for multiple groups, and were statistically Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S110 Reference 1. Figure 1 (abstract P325). Efects of bed height position on intrathoracic pressure generated after 30 seconds of CPR. n = 101. *Statistically signiicant (P <0.05). Figure 2 (abstract P325). Mean intrathoracic pressures generated during CPR at 30 seconds as compared with 2 minutes. *Statistically signiicant (P <0.05). signiicant with P <0.01 (Figure 1). We also found that the efectiveness of CPR decreased 17% over a 2-minute period (Figure 2). Conclusions The most efective bed height position, allowing rescuers to achieve the highest intrathoracic pressures during CPR, was with the patient chest in line with the rescuer’s mid-thigh. The rescuer performing CPR should change every 2 minutes. Reference 1. Resuscitation 2005, 67:187-201. P326 New results about early therapeutic hypothermia in sudden cardiac death and following return of spontaneous circulation FR Righetti, AL Luzzani, EP Polati 1 Ospedale Policlinico Universitario, Verona, Italy Critical Care 2010, 14(Suppl 1):P326 (doi: 10.1186/cc8558) Introduction Therapeutic hypothermia is deined as controlled cooling of body temperature for therapeutic purposes. At present, the use of mild– moderate hypothermia (32 to 34°C) in patients with neurological damage is increasing in the ICU. In this regard, recent studies suggest that it is able to improve the neurological outcome in patients with anoxic cerebral damage following sudden cardiac death (SCA) [1]. The aim of this study is to assess the role of therapeutic hypothermia on neurological outcome in patients who experienced SCA with ensuing return of spontaneous circulation (ROSC). Methods Ninety adult patients, aged between 18 and 85, referred to our ICU after SCA due to cardiac disease with following ROSC were randomly allocated to the following treatment groups: patients in group 1 were treated immediately after admission with therapeutic hypothermia plus standard treatment, patients in group 2 received only standard treatment. All patients at entry presented with GCS 3. Neurological outcome was assessed on discharge and after 6 months, by means of GOS scale (0 = dead, 1 = vegetative, 2 = severely disabled, 3 = moderately disabled, 4 = good recovery). We consider scores 0 to 1 as unfavourable outcome, scores from 2 to 4 as favourable outcome. To compare the two groups we used the Mann–Whitney U test of for continuous variables, the chi-square test for qualitative variables. Results Patients in group 1 (45 patients) and in group 2 (45 patients) resulted statistically comparable for sex (P = 0.14) and age (P = 0.68) and presentation ECG rhythm (P = 0.42) and APACHE II score (P = 0.34). At discharge from the ICU, 66.6% of patients in group 1 presented favourable neurological outcome (GOS 2 to 4) versus 35% of patients in group 2. At 6 months, 70% of patients in group 1 presented favourable neurological outcome (GOS 2 to 4) versus 38.3% of patients in group 2. The mortality was 16.6% in group 1 versus 36.6% in group 2 (P = 0.003). The patients who improved their GOS values were 64% in group 1 and 18% in group 2 (P <0.005). Conclusions Our study demonstrated that early treatment with therapeutic hypothermia in the patient who had SCA improves neurological outcome. It is independent of the rhythm of presentation. Besides, we reached statistical signiicance. Polderman KH, et al.: Therapeutic hypothermia and controlled normotermia in the intensive care unit: practical considerations, side efects, and cooling methods. Crit Care Med 2009, 37:1101-1120. P327 Infection rates among cooled patients post cardiac arrest A Binks, MJ Thomas Bristol Royal Inirmary, Bristol, UK Critical Care 2010, 14(Suppl 1):P327 (doi: 10.1186/cc8559) Introduction We conducted a retrospective study looking at infection rates in patients treated with therapeutic hypothermia (TH) following cardiac arrest who were admitted to the ICU of the Bristol Royal inirmary since May 2007. TH is recommended in all patients presenting with persistent coma following cardiac arrest. One complication of TH is the risk of infection. Hypothermia suppresses the immune system by inhibiting the release of proinlammatory cytokines and by suppressing the chemotactic migration of leukocytes and phagocytosis [1]. In patients with traumatic brain injury, TH for more than 48 hours is associated with a higher risk of infection, but not if the period of hypothermia is less than 24 hours [2]. In patients following cardiac arrest, infection is common, reported in up to 73% of patients [3]. Methods Data were collected retrospectively, and information about ICU length of stay, whether they had a protected catheter (PC) specimen taken, whether they had any positive cultures and whether they were treated with antibiotics was extracted. Data for ICU length of stay was also obtained. Infections were deined as >105 colony-forming units (cfu) grown from either PC specimens or from peripheral blood cultures. Results We identiied 82 patients treated with TH post cardiac arrest. Nineteen (29%) had proven infection either on PC or on peripheral blood cultures. PC specimens were taken in 21 (25%) patients. Of the 21 patients who had PC specimens taken, 16 (76%) had proven infection. We also found that an increase in ICU length of stay was associated with increased infection rates, 44% in patients with a length of stay of greater than 3 days and 55% in patients with a length of stay of greater than 4 days. Conclusions We have shown, in our ICU, that of patients who were treated with TH following cardiac arrest, 29% had a proven infection. On PC sampling, there was a much higher rate of infection with 76% of patients with positive cultures. This suggests that the risk of infection in patients treated with therapeutic hypothermia post cardiac arrest is higher than that for patients who are cooled post traumatic brain injury. References 1. 2. 3. Polderman KH: Intensive Care Med 2004, 30:556-575. Polderman KH: Crit Care Med 2009, 37:S186-S202. Tsai MS, et al.: Intensive Care Med 2005, 31:621-626. P328 Strategies to implement a therapeutic hypothermia program S Blosser, N Cavarocchi, S Ettinger, IC Gilchrist, R Reichwein, S Bressler, J Burkholder, E Sarsield, K Zagari Penn State Hershey Medical Center MCH075, Hershey, PA, USA Critical Care 2010, 14(Suppl 1):P328 (doi: 10.1186/cc8560) Introduction In this presentation we will review the process used for developing a therapeutic hypothermia program and our outcomes during the irst year. Despite the fact that therapeutic hypothermia has been shown to improve survival and neurologic outcome after cardiac arrest [1], it is underused [2] and has been only slowly introduced in many institutions. One of the reasons that it is not more widely used may be the diiculty of implementation of a program. Methods A multidisciplinary team was assembled in 2007 to explore the opportunity for therapeutic hypothermia in patients after cardiac arrest. Pertinent literature was reviewed and a guideline and electronic orders were drafted. The team investigated all available options for cooling and chose a method that was non-invasive and did not require a large inancial investment by the institution. Nurses were sent to an international program to learn about hypothermia and become advocates Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 and educators. Education was done for caregivers in the prehospital setting, emergency department, cardiac catheterization laboratory, and adult ICUs. Advertising to community and other hospitals was done by newspaper, radio, and television. The team continued to meet regularly to assess and modify the program based on experience. Results Prior to the start of this program, therapeutic hypothermia was essentially not utilized at the institution. Twenty-one patients were cooled after cardiac arrest and resuscitation at our institution in the irst year (2008), with few missed opportunities. Fifteen (71%) survived, and 12 (57%) had good neurologic outcome. (Post-cardiac arrest survival rates without hypothermia in the literature range from less than 5% to 35% [1].) Challenges included altering historic practice patterns, integrating sectors of the healthcare delivery system that had historically drifted apart, and interacting with extra-institutional regulations governing prehospital care. Conclusions The therapeutic hypothermia program at our institution is successful in improving patient outcome after cardiac arrest. The elements that contributed to a successful program included: teamwork; multidisciplinary nature of the team; promoting awareness of the program; buy-in by nurses who championed the program in the ICU; positive patient outcomes; and low inancial investment for the institution. References 1. 2. Bernard SA, et al.: N Engl J Med 2002, 346:557-563. Brigham BL, et al.: Resuscitation 2009. [Epub ahead of print] P329 A comparison of core and tympanic temperature measurement in the critically ill B Sanderson, L Lim, K Lei, J Smith, L Camporota, R Beale Guys and St Thomas’ NHS Foundation Trust, London, UK Critical Care 2010, 14(Suppl 1):P329 (doi: 10.1186/cc8561) Introduction Measurement of body temperature using the tympanic method (TTM) represents a standard non-invasive method which best approximates core temperature (CTM). However, published evidence increasingly casts doubt on the agreement between TTM and CTM. The aim of this study was to assess the agreement of these two methods of temperature measurement in critically ill patients. Methods We recruited 20 consecutive critically ill patients, who required indwelling thermistor-tipped arterial catheters for haemodynamic monitoring. For each patient we simultaneously collected the core temperature, obtained from the arterial catheter, and tympanic temperatures in the left and right ears, in the supine position. Tympanic temperature was recorded using the ear setting (TTMe) and the core setting tympanic temperature (TTMc) in accordance with the manufacturer’s instructions (Genius™ 2; Kendall, Tyco Healthcare, MA, USA). Local ethics committee approval was waived and the study was conducted as a service improvement audit. Bland–Altman analysis was used to measure agreement between the two set of measurements. Results From the 20 patients we made 102 paired measurements. Comparison of the TTM in the right and left ears resulted in high variability in the recorded temperature with a percentage error of 34.4%. In view of this observed large variability, the mean TTM between the two ears was used for subsequent comparison with core temperature. Comparison of core measurements against tympanic measurements using ear settings (TTMe) showed a small positive mean bias (limits of agreement (LOA); percentage error) of 0.3°C (–0.4 to 1.1°C, 2.4%). However, when the CTM and TTM were compared using the core temperature setting of the thermometer, the bias (LOA) increased to –0.97°C (–1.6 to –0.4°C), creating a larger bias than the unadjusted TTM. Conclusions Tympanic temperature measurements showed a large random variability compared with core temperatures and suggest bilateral averaged tympanic measurements may be necessary. In our series, using the core setting increased error and increased the bias between the two methods. Our indings raise the possibility that the diagnosis of fever and the need for further investigation may be afected by the choice of temperature measurement site and device setting used. S111 P330 Can we predict neurological prognoses with computed tomography just after resuscitation? T Mochizuki1, N Otani1, O Takahashi2, S Ishimatsu1 1 St Luke’s International Hospital, Tokyo, Japan; 2St Luke’s Life Science Institute, Tokyo, Japan Critical Care 2010, 14(Suppl 1):P330 (doi: 10.1186/cc8562) Introduction Noncontrast computed tomography (CT) is often used to evaluate a primary catastrophic brain injury after cardiac arrest. On day 3 after resuscitation, cerebral damage presents as swelling on CT; however, there is no strong evidence associated with how prognosis is predicted on CT performed just after resuscitation. We assessed whether the ratio (in Hounsield units (HU)) of grey matter (GM) to white matter (WM) on CT performed just after resuscitation can be used as a predictor of patient outcome. Methods We utilized the electronic medical record to examine admission to the ICU after resuscitation from out-of-hospital cardiac arrest. Brain CTs performed just after resuscitation were re-evaluated. Patients were excluded if they had head trauma, cerebral vessel disease and were 16 years of age or younger. Clinical outcome was assessed at the time of discharge using the Pittsburgh cerebral performance category (CPC). On noncontrast CTs, HU were measured as GM in the regions of bilateral caudate head, putamen, globus pallidaus and cortical layer of the precentral sulcus, and as WM in the regions of the periventricular WM. We deined good neurological prognosis as CPC 1 to 2 and an unfavorable prognosis as CPC 3 to 5. Each ratio of average GM to WM was calculated, and they were compared with a good outcome and an unfavorable outcome. Results In 1,057 episodes of out-of-hospital cardiac arrest, 296 were resuscitated and admitted to our ICU; 64 were excluded, and the inal study sample consisted of 232 patients. CPC 1 to 5 at hospital discharge was 16%, 6%, 6%, 12% and 60%. The mean time from arrival to perform brain CT was 66 (25 to 330) minutes. The HU of caudate head, putamen and globus pallidaus were much higher in good outcome than in unfavorable outcome (P <0.001, t test). The HU of cortical layer of the precentral sulcus and periventricular WM were not signiicantly diferent. The caudate head/WM ratio and globus pallidaus/WM ratio were much higher in good outcome (P <0.01, t test). Using ROC analysis, we determined that a caudate head/WM ratio >1.21 or a globus pallidaus/WM ratio >1.17 was 90% predictive of a good outcome in this study. Conclusions The caudate head/WM ratio and globus pallidaus/WM ratio by brain CT just after resuscitation are useful to predict the postresuscitation neurological prognosis. Reference 1. Wijdicks EFM, et al.: Neurology 2006, 67:203-210. P331 Unintended consequences of technology improvement W McGee, PM Mailloux Baystate Medical Center, Springield, MA, USA Critical Care 2010, 14(Suppl 1):P331 (doi: 10.1186/cc8563) Introduction Technological improvements in ventilator design may confound the diagnosis of brain death. We describe a series of patients clinically perceived to be breathing spontaneously even though they satisied the criteria for brain death. The misdiagnosis of cerebral function in these patients delayed the diagnosis of brain death and subsequent organ donation. Resource utilization, patient/family sufering, and staf morale are all negatively impacted when this occurs. Methods The ventilator triggering mode was recorded in all patients. Patients were identiied by the authors with a high likelihood of brain death and receiving pressure support ventilation. Patients without cranial nerve function underwent formal apnea testing. Results Seven patients were identiied with cessation of cranial nerve function, but thought to have spontaneous breathing activity. All patients were on pressure support ventilation with low triggering. Formal apnea testing was performed (Table 1). Conclusions Improvement in triggering ventilation may confound the diagnosis of brain death. Considering the unmet need for transplantation and the negative impact of not recognizing death on families, staf, resource utilization and both patients and potential recipients of organs mandates a simple solution to eliminate these problems. We propose that Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S112 Table 1 (abstract P331) Patient Injury Apnea Outcome 42 years old, male Gunshot Yes Donor 27 years old, male TBI Yes DCD 73 years old, male TBI Yes Donor 52 years old, female 66 years old, male 56 years old, female 43 years old, male ICH Yes No Anoxia Yes No Anoxia Yes Donor Gunshot Yes Donor DCD, donor after cardiac death; TBI, trauma brain injury; ICH, intracranial hemorrhage. in all patients being evaluated for brain death once cranial function has ceased an apnea test should be carried out promptly with the patient disconnected from the ventilator. P332 Bispectral Index Scale alterations in brain death patients V Grosomanidis1, B Fyntanidou1, K Kotzampassi2, E Thomaidou1, V Ourailoglou1, G Thoma1, C Skourtis1 1 Department of Anaesthesiology and 2Department of Surgery, University of Thessaloniki Medical School, Thessaloniki, Greece Critical Care 2010, 14(Suppl 1):P332 (doi: 10.1186/cc8564) Introduction Brain death (BD) is deined as the total and irreversible loss of brain function, including the brain stem. According to current Greek guidelines, low BD diagnosis is determined only by clinical criteria, thus electroencephalogram (EEG), cerebral angiography or transcranial Doppler are not considered mandatory for BD conirmation. The Bispectral Index Scale (BIS) is a multifactorial parameter derived from the EEG, which allows monitoring of the hypnotic component of anaesthesia. Furthermore, it has been reported that there is a good correlation between BIS and neurological status in unsedated coma patients. In addition, it has been recently suggested that BIS is associated with the Glasgow Coma Score (GCS) and could serve as a good predictor tool for the outcome after head trauma. Moreover it has been reported that BIS can be used in the early detection of BD. The aim of the present study was to record the BIS alterations in BD patients. Methods Thirty brain injury patients (24 males and six females, with a mean age of 48.4 ± 12.3 years) who were considered as being BD according to the standard clinical criteria were included in the study. Eleven of them became organ donors. Continuous BIS monitoring (BIS; Aspect Medical Systems Inc., Natick, MA, USA) was performed for 24 to 32 hours (mean 26.7 hours). Results All patients were haemodynamically stable, normothermic and without any electrolytical disturbance. Ten patients showed BIS 0 continuously. In the remaining 20 patients (66.6%) BIS luctuations over 30 continuing for more than 30 minutes were recorded. These values then dropped to the BIS 0 level after diferent time periods. These alterations were compatible with EEG activity and not associated with external stimulus such as surgical or other manipulations. Conclusions BIS monitoring is a continuous, simple method, easily interpreted. Although it has been suggested to be a good predictor tool of early detection of BD, there is a possibility of increased BIS values in BD patients. The anaesthesiologist should be aware of these situations and in no case should the BIS indings decrease the validity of standard clinical criteria of BD determination. P333 Prognosis in patients presenting with nontraumatic coma S Forsberg, J Höjer, U Ludwigs Karolinska Institute, Stockholm, Sweden Critical Care 2010, 14(Suppl 1):P333 (doi: 10.1186/cc8565) Introduction Studies of patients presenting with coma are limited and little is known about the prognosis of these cases [1-3]. The aim of this study was to investigate the acute and long-term prognosis after an episode of nontraumatic coma. Methods Adults admitted consecutively to an emergency department in Stockholm, Sweden between February 2003 and May 2005 with a Glasgow Coma Scale (GCS) score of 10 or below were enrolled prospectively. All available data were used to explore the cause of the impaired consciousness on admission. Patients surviving hospitalization were followed up for 2 years regarding survival. Results The inal study population of 865 patients had the following eight diferent coma etiologies: poisoning (n = 329), stroke (n = 213), epilepsy (n = 113), circulatory failure (n = 60), infection (n = 56), metabolic disorder (n = 44), respiratory insuiciency (n = 33), and intracranial malignancy (n = 17). The hospital mortality rate among the 865 patients was 26.5%, varying from 0.9% for epilepsy to 71.7% for circulatory failure. The accumulated total 2-year mortality rate was 43.0%, varying from 13.7% for poisoning to 88.2% for malignancy. The level of consciousness on admission also inluenced the prognosis: a GCS score of 3 to 6. Conclusions The prognosis in patients presenting with nontraumatic coma is serious and depends largely both on the level of consciousness on admission and on the etiology of the coma. Adding the suspected coma etiology to the routine coma grading of these emergencies may more accurately predict their prognosis. References 1. 2. 3. Martikainen K, Seppä K, Viita P, Rajala S, Laippala P, Keränen T: Transient loss of consciousness as reason for admission to primary health care emergency room. Scand J Prim Health Care 2003, 21:61-64. Kanich W, Brady WJ, Huf JS, Perron AD, Holstege C, Lindbeck G, Carter CT: Altered mental status: evaluation and etiology in the ED. Am J Emerg Med 2002, 20:613-617. Levy DE, Bates D, Caronna JJ, et al.: Prognosis in nontraumatic coma. Ann Intern Med 1981, 94:293-301. P334 Dynamic changes in cerebral oxygenation by two methods during cardiac surgery and postoperative cognitive decline Y Kakihana, N Kiyonaga, T Yasuda, T Imabayashi, T Ohryoji, M Nakahara, N Okayama, Y Kanmura, T Kikuchi, T Yonemitsu Division of Intensive Care Medicine, Kagoshima University Hospital, Kagoshima, Japan Critical Care 2010, 14(Suppl 1):P334 (doi: 10.1186/cc8566) Introduction Recently, near-infrared time-resolved spectroscopy (TRS), which is quite efective in quantitative monitoring tissue oxygenation, because it ofers the actual measurement of photon migration in the tissues, and the photon mean path length is easily obtained from the center of gravity of the temporal proile, has been developed. In this study, we investigated whether the changes in the cerebral oxygen saturation (T-SO2) obtained with the TRS and the jugular venous oxygen saturation (SjvO2) predicted cognitive decline after cardiac surgery. Methods With institutional approval and informed consent, we studied 10 patients (68.7 ± 6.1 years) undergoing cardiac surgery under cardiopulmonary bypass (CPB). T-SO2 was continuously monitored using a TRS-10 (Hamamatsu Photonics KK, Hamamatsu, Japan). For measurement of SjvO2, a 5.5 Fr oximetry catheter was inserted by retrograde cannulation of the right internal jugular vein. The values of T-SO2 and SjvO2 were compared with each point: before CPB, 5 minutes after the onset of CPB, before aorta clamp, after aorta clamp, rewarming, aorta declamp, end of rewarming, and end of CPB. The cognitive decline was evaluated by Mini Mental State Examination before and 7 days after the operation. The statistical analysis was performed by repeated-measures ANOVA followed by Fisher’s PLSD. P <0.05 was considered statistically signiicant. Results Four of 10 cases showed postoperative cognitive decline. The mean values of T-SO2 and SjvO2 during operation in patients without postoperative cognitive decline (n = 6) were 63.9 ± 4.6% and 60.5 ± 9.7%, respectively, and there were no statistical signiicances between these values. However, the mean values of T-SO2 and SjvO2 during operation in patients with postoperative cognitive decline (n = 4) were 62.8 ± 5.6% (T-SO2) and 70.4 ± 14.9% (SjvO2), and showed signiicant diferences between two values (P = 0.0024), and at the rewarming period, the values of SjvO2 was signiicantly higher than those of T-SO2 (87.9 ± 6.3% vs 65.0 ± 5.3%, P = 0.0014). Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Conclusions Our results demonstrate a lack of agreement between SjvO2 and T-SO2 for monitoring cerebral oxygenation at the occurrence of postoperative cognitive decline. Therefore, we conclude that the two methods are not interchangeable, and the TRS instrument may be useful for obtaining accurate values for cerebral oxygen saturation under CPB. P335 Acetazolamide-induced cerebrovascular reactivity is impaired in sepsis-associated encephalopathy S Szatmari, T Végh, C Molnár, C Antek, B Fülesdi University of Debrecen, Hungary Critical Care 2010, 14(Suppl 1):P335 (doi: 10.1186/cc8567) Introduction The pathophysiology of sepsis-associated encephalopathy (SAE) is not entirely clear. One of the possible underlying mechanisms is the alteration of the cerebral microvascular function induced by the systemic inlammation. The aim of the present work was to test whether cerebral vasomotor reactivity is impaired in patients with SAE. Methods Patients fulilling the criteria of clinical sepsis and showing disturbance of consciousness of any severity were included. Nonseptic persons without previous diseases afecting cerebral vasoreactivity served as controls. Transcranial Doppler blood low velocities were measured at rest and at 5, 10, 15 and 20 minutes after intravenous administration of 15 mg/kg BW acetazolamide. The time course of the acetazolamide efect on cerebral blood low velocity (cerebrovascular reactivity, CVR) and the maximal vasodilatory efect of acetazolemide (cerebrovascular reserve capacity, CRC) were compared among the groups. Results Fourteen patients with SAE and 20 controls were included. Absolute blood low velocities after administration of the vasodilator drug were higher among control subjects than in SAE. Assessment of the time course of the vasomotor reaction showed that patients with SAE reacted slower to the vasodilatory stimulus than control persons. When assessing the maximal vasodilatory ability of the cerebral arterioles to acetazolamide during vasomotor testing, we found that patients with SAE reacted to a lesser extent to the drug than did control subjects (CRC SAE: 46.2 ± 15.9%, CRC controls: 29.4 ± 15.8%, P <0.01). Conclusions We conclude that cerebrovascular reactivity is impaired in patients with SAE. References 1. 2. 3. Wilson JX, Young GB: Sepsis-associated encephalopathy: evolving concepts. Can J Neurol Sci 2003, 30:98-105. Matta BF, Stow PJ: Sepsis-induced vasoparalysis does not involve the cerebral vasculature: indirect evidence from autoregulation and carbon dioxide reactivity studies. Br J Anaesth 1996, 76:790-794. Settakis G, Molnár C, Kerényi L, et al.: Acetazolamide as a vasodilatory stimulus in cerebrovascular diseases and in conditions afecting the cerebral vasculature. Eur J Neurol 2003, 10:609-620. S113 Results We studied 1,504 patients submitted to ablation. There 1,120 were females (74.46%) and 384 males. The average age was 52 years. Hunt–Hess scale prevalence: 1 – 67.88%, 2 – 18.62%, 3 – 8.19, 4 – 4.92%, 5 – 2.32%, and Fisher: 1 – 62.58%, 2 – 7.91%, 3 – 17.08%, 4 – 7.58%. The main risk factors involved in the cerebral vascular accident were: systemic arterial hypertension 40.4% (n = 608) and smoking 30.8% (n = 463). The arteries more involved were: posterior communicant = 381 (25.33%), median cerebral = 296 (19.61%) and anterior communicant = 254 (16.87%). A total 72.67% of patients presented only one aneurysm (n = 1,093) and 27.33% two or more aneurysms (n = 411). We observed an occurrence of 1,217 (80.91%) ruptured aneurysms and 287 incidental. The sizes of the aneurysms were: 46.30% standard aneurysms (between 5 and 25 mm), 47.95% smaller than 5 mm and 5.75% giant. The aneurysms were narrow neck in 37.78% of the cases (n = 1,082), and large in 14.34% (n = 412). Among the 218 events that occurred, there were coils into the vascular lumen in 96 cases (6.38%), bleeding in 58 (3.85%) and others. The materials used were: 334 balloons and 136 stents. Angiographic vasospasm occurred in 178 patients. Conclusions There was a predominance of females for the occurrence of cerebral vascular aneurysmatic accident. The average age was 52 years. Systemic hypertension and smoking showed strong association with the rupture of intracranial aneurysms. The arteries of the previous segment were those that had higher incidence of aneurysms. More than onehalf of the patients did not have complications during the procedure. Embolization of cerebral aneurysms was revealed to be a low lethality method. P337 Frequency/prevalence analysis of risk factors on aneurysmal subarachnoid hemorrhage S Kifer Macedo, CM Primo de Siqueira, S Boechat Primo de Siqueira, R Mendoza Nuss, L Carvalho Dias, A Cedro Souza, G Vieira Rangel Pereira Hospital São José do Avaí, Itaperuna, Brazil Critical Care 2010, 14(Suppl 1):P337 (doi: 10.1186/cc8569) Introduction Subarachnoid hemorrhage (SAH) is a catastrophic clinical event in which 2/3 of spontaneous SAH are characterized by rupture and bleeding of cerebral aneurysm. Methods After institutional approval and informed consent, this prospective observational study took place from April 2008 to November P336 Epidemiological analysis of patients with cerebral aneurysms submitted to embolization at São José do Avaí Hospital S Kifer Macedo, CM Primo de Siqueira, S Boechat Primo de Siquiera, L Amaral de Oliveira, L Carvalho Dias, N Raissa da Matta, E Abreu Reis Vargas de Almeida, L Bonani Brito, A D’Ávila Carvalho, N Ferreira Bastos São José do Avaí Hospital, Itaperuna, Brazil Critical Care 2010, 14(Suppl 1):P336 (doi: 10.1186/cc8568) Introduction Cerebral aneurysms afect between 1 and 5% of the adult population and are responsible for signiicant rates of morbidity and mortality. The treatment of intracranial aneurysms evolved substantially since the introduction of endovascular neurosurgery by Guglielmi detachable coils (GDC) in the 1990s. The ablation overtook a clipping as the initial method in many centers, including Brazil, because of the safety and feasibility of this method. Methods This cohort retrospective study analyses clinical and epidemiological variables. It was conducted from the database of patients submitted to ablation in the neurosurgery department of São José do Avaí Hospital in the period of December 2006 to November 2009. Figure 1 (abstract P337). Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 2009, involved all adult patients with spontaneous SAH admitted to the ICU, evaluating the frequency/prevalence of some factors such as: gender, age, skin color, arterial hypertension (AH), smoking habit, diabetes mellitus (DM), alcoholism, dyslipidemia, sedentary and use of oral contraceptive method. Results We observed a total of 128 patients, average age of 55.3 years, and obtained as the main results of frequency with respective conidence intervals (CI): gender, female 73.4% (n = 94) (CI 64.9 to 80.9), male 26.6% (n = 34) (CI 19.1 to 35.1); skin color, white 46.2% (n = 54) (CI 36.9 to 55.6), black 24.8% (n = 29) (CI 17.3 to 33.6), brown 29.1% (n = 34) (CI 21.0 to 38.2); AH, yes 72.7% (n = 93) (CI 64.1 to 80.5), no 27.3% (n = 35) (CI 19.8 to 35.9); smoking habit, yes 44.5% (n = 57) (CI 35.7 to 53.6), no 55.5% (n = 71) (CI 46.4 to 64.3); diabetes mellitus, yes 14.8% (n = 19) (CI 9.2 to 22.2), no 85.2% (n = 109) (CI 77.8 to 90.8); alcoholism, yes 12.6% (n = 16) (CI 7.4 to 19.7), no 87.4% (n = 112) (CI 87.4 to 92.6); dyslipidemia, yes 10.9% (n = 14) (CI 6.1 to 17.7), no 89.1% (n = 114) (CI 82.3 to 93.9); sedentary, yes 25.8% (n = 33) (CI 18.5 to 34.3), no 74.2% (n = 95) (CI 65.6 to 81.5); obesity, yes 11.7% (n = 15) (CI 6.7 to 18.6), no 88.3% (n = 113) (CI 81.4 to 93.3); oral contraceptive method (analysis obtained only for female gender population), yes 5.3% (n = 5) (CI 1.7 to 12.0), no 94.7% (n = 89) (CI 88.0 to 98.3). See Figure 1. Conclusions We can show that among all RF, female gender, AH and smoking habit had greatest prevalence index; the factor skin color had a wide distribution from its variants; other RF as DM, alcoholism, dyslipidemia, sedentary, and use of oral contraceptives had not obtained signiicant prevalence on patients with aneurysmal SAH. Reference 1. Krishna V, Kim DH: J Neurosurg 2007, 107:522-529. S114 P339 Early prognosis value of the irst 24 hours mean plasma S100β protein level after subarachnoid aneurysmal hemorrhage D Frasca, A Proust, C Millet, B Debaene, O Mimoz, C Dahyot-Fizelier University Hospital, Poitiers, France Critical Care 2010, 14(Suppl 1):P339 (doi: 10.1186/cc8571) Introduction Plasma S100β protein (PS100β) was described as a biological marker of white substance damage and brain ischemia. Studies of new neuroprotective approaches in patients with traumatic brain injury and subarachnoid aneurysmal hemorrhage would beneit from the development of such markers. The aim of this study was to evaluate the irst 24 hours mean plasma PS100β for predicting outcome at ICU discharge after subarachnoid aneurysmal hemorrhage (SAH). Methods From August 2006 to August 2008, 100 patients (46 men and 54 women; mean age 52 ± 11 years) were admitted for SAH and treated by surgical clipping or coiling within 2 days after admission. SAPS II, World Federation of Neurological Surgeons (WFNS), Fisher and Glasgow Outcome Scale (GOS) were scored at ICU discharge. Plasma S100β concentrations were assayed at admission (hours 0, 6 and 24) and daily up to day 12 (routine procedure). Statistical analysis relied on the mean irst 24 hours PS100β and the main outcome criterion was the GOS score at discharge dichotomized as poor (GOS 1 to 3) or good (GOS 4 to 5). Results Poor outcome was associated with high mean irst 24 hours PS100β, high initial WFNS and Fisher scores in univariate analysis (P <0.0001). The best cut-of for the mean irst 24 hours S100β value was 0.15 μg/l (speciicity 0.60, 95% conidence interval (CI) 0.52 to 0.67; sensitivity 0.85, 95% CI 0.79 to 0.89; area under the curve 0.83, 95% CI 0.69 to 0.92; Figure 1). P338 Monitoring regional brain oxygen saturation in patients with clipped aneurysms of the anterior circle of Willis R Gendek1, K Kusza2 1 10th Military Clinical Hospital, Bydgoszcz, Poland; 2University of Nicolaus Copernicus, Collegium Medicum of Ludwik Rydygier, Bydgoszcz, Poland Critical Care 2010, 14(Suppl 1):P338 (doi: 10.1186/cc8570) Introduction The objective of this work was to assess the usefulness of monitoring regional brain oxygen saturation (rSO2) in the identiication of intraoperative episodes of cerebral ischemia during the surgical clipping of brain aneurysms. Moreover it aimed to verify whether this kind of monitoring afects the incidence of postoperative neurological deicits. Methods We monitored 50 patients undergoing cerebral aneurysm clipping with the use of Somanetics INVOS Cerebral Oximeter 4100. The alarm threshold of rSO2 was deined as a minimum of 20% drop from baseline, triggering intervention aimed at increasing rSO2 values. Results Eleven cases of postoperative deterioration of neurological status were noted, of which six were reversible. Additional intraoperative events, such as numerous surgical clip displacements, temporary clipping, aneurysm ruptures, and trapping occurred in 16 cases. On the operated side, a rapid, lasting increase of rSO2 values was noted in nearly one-half of the cases; implying an artifact caused by the neurosurgical procedure. On the nonoperated side, seven cases of rSO2 values dipping below the alarm threshold were noted. In all cases intervention led to an increase and normalization of rSO2 values in a relatively short time. Since the values registered in the frontal lobe on the nonoperated side were considered representative of the entire brain, the balance of cerebral oxygen supply and consumption was seen as intraoperatively preserved. The comparison between two groups of patients, with and without neurological deicits developed in the postoperative period, revealed no disparities in cerebral oximetry values on the nonoperated side, nor in the range of other monitored physiological parameters. In 10 out of 16 cases involving additional intraoperative events, deterioration of neurological status was noted (62.5%), while in the remaining cases only one such occurrence was registered (2.95%). Conclusions Monitoring regional brain oxygen saturation on the operated side is a method hampered by a large percentage of false results, and thus is a monitoring tool of little prognostic value. Assuming that the frontal lobe on the nonoperated side is representative of the entire brain with regard to rSO2 measures, the maintenance of oxygen supply and demand balance does not safeguard the brain against ischemic lesions in the supply area of the operated artery. Figure 1 (abstract P339). ROC curve of the irst 24 hours mean PS100β value and outcome at ICU discharge. Conclusions The mean PS100β value assessed during the irst 24 hours is a prognostic tool complementary to initial clinical evaluation in SAH patients. P340 Altered aortic stifness associated with stress cardiomyopathy in patients with aneurysmal subarachnoid haemorrhage I Papanikolaou1, M Fragou2, P Zotos2, D Karakitsos2, A Patrianakos3, E Zakinthinos1, A Karabinis2 1 University Hospital of Larissa, Greece; 2General Hospital of Athens, Greece; 3 University Hospital of Heraklion, Crete, Heraklion, Greece Critical Care 2010, 14(Suppl 1):P340 (doi: 10.1186/cc8572) Introduction We investigated whether possible alterations in aortic stifness were associated with stress cardiomyopathy (SC) in patients with subarachnoid haemorrhage (SAH). Methods Thirty-seven patients with SAH (aged 42.65 ± 13.07, 23 males) were included in the study. The severity of SAH was estimated by HuntHess and Fisher scales, respectively. The left ventricular ejection fraction (LVEF) was measured by the Simpson’s biplane method of disks; aortic Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 stifness was assessed by sonographic measurements of the carotid to femoral pulse wave velocity (PWV). The above sonographic measurements along with BNP measurements were obtained upon admission and repeated measurements were performed 20 ± 2 days following the acute phase of SAH. All patients were mechanically ventilated under the same conditions during all measurements. Results Patients with severe SAH showed depressed LV function and increased aortic stifness. Both Hunt–Hess and Fisher scales were associated with LVEF (r = –0.460, P = 0.004 and r = –0.512; P = 0.001, respectively) and PWV values (r = 0.359, P = 0.029 and r = 0.363; P = 0.027, respectively). On admission, 14 patients (38%) manifested SC with increased BNP values as compared with those without cardiac alterations (841.43 ± 561.04 vs 145.04 ± 106.02 pg/ml, P <0.001). These subjects exhibited increased PWV as compared with patients with normal LV function (12.79 ± 2.02 vs 9.63 ± 2.89 m/second, P = 0.001). PWV correlated to BNP values (r = 0.489, P = 0.002). Follow-up measurements revealed a signiicant increase in LVEF and decrease in PWV as compared with baseline measurements (62.64 ± 9.18 vs 57.94 ± 12.55%, P = 0.005 and 9.37 ± 2.07 vs 10.71 ± 2.96 m/second, P = 0.001, respectively). In this series, brain death was documented clinically in seven cases. An ongoing study including a larger number of patients with SAH analyzes the prognostic value of echocardiographic and BNP measurements. Conclusions Alterations of the heart–vessel coupling may be due to catecholamine-induced mechanisms. Stress cardiomyopathy associated with altered aortic stifness during the acute phase of SAH may be transient phenomena. P341 Efect of packed red blood cell transfusion on cerebral oxygenation and metabolism after subarachnoid hemorrhage P Kurtz, R Helbok, J Claassen, J Schmidt, L Fernadez, R Stuart, ES Connoly, K Lee, SA Mayer, N Badjatia Columbia University Medical Center, New York, USA Critical Care 2010, 14(Suppl 1):P341 (doi: 10.1186/cc8573) Introduction Anemia is frequently encountered in critically ill patients and adversely afects cerebral oxygen delivery and metabolic function. However, there is limited evidence to support the use of packed red blood cell (PRBC) transfusion to optimize brain homeostasis after subarachnoid hemorrhage. The objective of this study was to investigate the efect of PRBC transfusion on cerebral oxygenation and metabolism in patients with subarachnoid hemorrhage. Methods Prospective observational study in a neurological ICU of a university hospital. Nineteen PRBC transfusions were studied in 15 consecutive patients with subarachnoid hemorrhage that underwent multimodality monitoring (intracranial pressure, brain tissue oxygen and cerebral microdialysis). Data were collected at baseline and during 12 hours after transfusion. The relationship between Hb change and lactate/pyruvate ratio (LPR) and brain tissue oxygen (PbtO2) was tested in univariate and multivariable analyses. Results PRBC transfusion was administered on median post-bleed day 8. The average Hb concentration at baseline was 8.1 g/dl and increased by 2.2 g/dl after transfusion. After transfusion initiation, PbtO2 increased between hours 2 and 4 and this rise was maintained until hour 10. LPR Figure 1 (abstract P341). S115 did not change during the 12 hours of monitoring. Multivariable analysis demonstrated that, after adjusting for peripheral oxygen saturation, cerebral perfusion pressure and LPR, the change in Hb concentration was independently and positively associated with change in PbtO2 (adjusted b estimate = 1.39 (95% conidence interval 0.09 to 2.69); P = 0.036). No relationship between change in LPR and change in Hb was found. Conclusions Transfusion of PRBC results in PbtO2 improvement without a clear efect on cerebral metabolism after subarachnoid hemorrhage. P342 Comparison of surgical or endovascular treated aneurismal SAH patients with a special emphasis on cerebral vasospasm I Akinci, C Kamar, E Guresti, A Sencer, S Sencer, T Kiris Istanbul Medical Faculty, Istanbul, Turkey Critical Care 2010, 14(Suppl 1):P342 (doi: 10.1186/cc8574) Introduction The aim of this study was to evaluate the incidence of delayed cerebral ischemia (DCI) and outcome in SAH patients who were admitted for surgical or endovascular procedures to treat cerebral aneurysm. Methods One hundred consecutive patients were evaluated according to their demographic data, severity of illness on admission, incidence of DCI, outcome and choice of treatment. The t test, Mann–Whitney U, and chi-square tests were used for statistical evaluation. Results Patients’ demographic data were as shown in Table 1. Clinical vasospasm diagnosis was made by the existence of three signs which are headache, neurological deicit, and worsening of Glasgow Coma Score (GCS). Due to this evaluation 28 of the patients demonstrated DCI. While 14 of them were in the clipping group (23.3%), the other 14 were in the coiling group (35%). But HHH therapy and CSF drainage with lumber puncture was started more liberally, in 57 and 35 patients respectively, due to at least two of the following indings or clinician’s decision: headache, agitation, elevated leukocyte level (without infection), new motor deicit and worsening in GCS. The severity of cases on admission in the clipping and coiling groups were similar for both. Although mortality and morbidity rates were higher in the coiling group there was no statistical diference in both groups (Table 2). Table 1 (abstract P342). Demographic data Age WFNS Fisher H&H Rankin GOS Hospital stay HHH therapy Clipping Coillin Clip + Coil Mortality 51 ± 11.2 1.3 ± 0.6 2.0 ± 1.0 1.8 ± 0.9 1.3 ± 1.5 4.4 ± 1.1 16.1 ± 12.0 58% 60% 38% 2% 5% GOS, Glasgow outcome score; H&H, Hunt and Hess. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S116 Table 2 (abstract P342) Age Clipping Coiling P NS 50.3 ± 11.6 52.6 ± 10.2 WFNS 1.2 ± 0.6 1.3 ± 0.7 NS Fisher 2.0 ± 1.1 2.0 ± 0.8 NS H&H 1.8 ± 0.4 1.7 ± 1.0 NS Rankin 1.1 ± 1.2 1.7 ± 1.8 NS NS GOS 4.6 ± 0.9 4.3 ± 1.2 17.1 ± 12.2 15.1 ± 11.7 NS DCI 23.3% 35% 0.25 Mortality 3.4% 7.5% 0.38 Hospital stay GOS, Glasgow outcome score; H&H, Hunt and Hess. Conclusions This study demonstrated that although mortality, morbidity rates and DCI incidence were lower in the surgical group, there was no statistical signiicance. P343 Prediction of cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage using jugular bulb oximetry monitoring: preliminary results R Souissi1, A Boubakker1, H Souissi2, A Abdelrazek1, M Badri1, S Bziouech1, H Jemel1 1 National Institute of Neurology, La Rabta, Tunisia; 2La Rabta Hospital, La Rabta, Tunisia Critical Care 2010, 14(Suppl 1):P343 (doi: 10.1186/cc8575) Introduction Cerebral vasospasm (CV) is the leading cause of death and disability in patients with subarachnoid hemorrhage (SAH). We suppose that clinical vasospasm disturbances could be detected by the increase in cerebral oxygen extractions (AVDO2), so in this study we tried to predict clinical CV appearances using jugular bulb oximetry monitoring. Methods Open prospective clinical study, from July 2009 to November 2009, in which 23 consecutive patients who underwent surgery for ruptured aneurysms were included; a jugular bulb catheter was placed in all patients. To calculate AVDO2, arterial and jugular bulb blood samples were taken every 12 hours. Demographics, neurological examination, WFNS grade, Fisher modiied classiication, aneurysm characteristics, vasospasm, and hemodynamic changes were collected. All patients presenting clinical vasospasm were treated by hypertensive, hemodilution and hypervolemic therapy (3H therapy). Adequate statistical tests were used. Results From 23 patients, eight had neurologic deicits (35%), in all these patients AVDO2 signiicantly increased approximately 12 hours before the onset of clinical deicits (P <0.01) and it was improved after administering 3H therapy. Two patients (8%) had clinical vasospasm but did not demonstrate a signiicant rise in AVDO2 (P <0.68), all other patients (57%) did not present clinical vasospasm nor signiicant rising in AVDO2. Conclusions Increases in AVDO2 using jugular bulb oximetry monitoring could predict clinical vasospasm in aneurysmal SAH hours before its onset. A larger number of patients would conirm these results. P344 Magnesium use on prophylaxis of vasospasm morbidity and mortality rate in subarachnoid hemorrhage S Kifer Macedo, CM Primo de Siqueira, S Boechat Primo de Siqueira, R Mendoza Nuss, L Carvalho Dias, A Cedro Souza, G Vieira Rangel Pereira Hospital São José do Avaí, Itaperuna, Brazil Critical Care 2010, 14(Suppl 1):P344 (doi: 10.1186/cc8576) Introduction Cerebral aneurysms are an important cause of morbidity and mortality of which the most severe consequence is their rupture. Subarachnoid hemorrhage (SAH) has arterial vasospasm as one of the most serious complications. Methods After institutional approval and informed consent, a prospective, randomized, single-blind study was carried out between February 2008 and November 2009. The study evaluated Mg use on patients from Beds 1 Figure 1 (abstract P344). Figure 2 (abstract P344). to 4 and the control group from Beds 5 to 8. The serum measure of Mg was made by colorimetric method in order to reach a measurement between 2.5 and 3.5 mg/dl, using a solution of Mg 2% (SG 5%, 400 ml + MgSO4 10%, 100 ml/24 hours), during the irst 14 days of the event (aneurysm rupture). Admission criteria: patients diagnosed with SAH conirmed by CT or cerebral angiography and Δt <96 hours. Exclusion criteria: patients with SAH and ΔT >96 hours; patients who presented a vasospasm episode in less than 24 hours of Mg solution infusion. Results In a previous study evaluation a total of 107 patients were analysed with n = 55 in Group 1 and n = 52 in Group 2 (Figures 1 and 2). The main results were: Group 1 – vasospasm frequency 20.0%, conidence interval (CI) = 10.4% to 33.3%; and mortality 16.4% in 28 days, CI =7.8% to 28.8; Group 2 – vasospasm frequency 51.9%, CI = 37.6% to 66.0%; and mortality 23.1% in 28 days, CI = 12.5% to 36.8%. The analysis for the vasospasm showed odds ratio (OR)= 0.23, CI = 0.098% to 0.544% and P = 0.0011, and for mortality: OR = 0.65, CI = 0.24% to 1.70% and P = 0.5284. Conclusions According to the outcome, we can conclude that Group 1 obtained a greater protection on the vasospasm incidence in comparison with Group 2 but showed no diference in mortality. The P value was signiicant for vasospasm but was still not signiicant for mortality. References 1. 2. Veyna RS, et al.: J Neurosurg 2002, 96:510-514. Knobel E, et al.: Condutas no Paciente Grave. São Paulo: Atheneu; 2006:871-883. P345 Efects of sinvastatin in prevention of vasospasm in nontraumatic subarachnoid hemorrhage: preliminary data S Kifer Macedo, CM Primo de Siqueira, S Boechat Primo de Siqueira, Y Brum Bello, A Campeão, L Carvalho Dias Hospital São José do Avaí, Itaperuna, Brazil Critical Care 2010, 14(Suppl 1):P345 (doi: 10.1186/cc8577) Introduction Vasospasm is the main cause of death and cognitive deicits in patients with subarachnoid hemorrhage after rupture of the aneurysm (aSAH). Some trials have shown that statins in the acute phase of aSAH reduces the incidence, morbidity and mortality of cerebral vasospasm. Methods We realized a prospective, randomized, nonblind study, with the use of 80 mg SVT (at night) in the irst 72 hours of the beginning of bleeding, and a control group that did not use SVT, for 21 days, between January and December 2008. Informed consent was obtained for all patients. CT scans was performed as control and another CT scan in patients with altered neurological signals. In the presence of changes suggestive of vasospasm or correlation in clinical and CT scans, the patients were taken for cerebral arteriography examination followed by an angioplasty procedure if necessary. Liver and renal function, LDL cholesterol evaluated weekly, and CK total evaluated every 3 days. Exclusion criteria: liver and renal disease, pregnant elevation of serum transaminases (three times the value of normal), creatinine ≥2.5, rhabdomyolysis or CK total ≥1,000 U/l. Results We excluded two patients with bleeding for more than 72 hours. There was no signiicant change in the levels of CK total, renal or liver function. We included 20 patients, 11 in the SVT group and nine in the control group. Mortality was eight patients (38%), six patients in the control group and two from the SVT group. Vasospasm was conirmed by Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 cerebral arteriography examination in four patients in the control group and one patient in the SVT group. All patients who died had Fisher scale IV. Conclusions SVT at a dose of 80 mg was efective in reducing the mortality (18.1% against 66%) compared with the group that did not use SVT, and also decreased the incidence of cerebral vasospasm despite higher APACHE II score in the group that used SVT (14.3 vs 10.7). There was less morbidity in the SVT group with an average of scale of Glasgow 3.25 vs 2.1. Reference 1. Lynch JR, Wang H, et al.: Simvastatin reduces vasospasm after aneurysmal subarachnoid hemorrhage: results of a pilot randomized clinical trial. Stroke 2005, 36:2024-2026. P346 Addition of new criteria to Sequential Organ Failure Assessment for patients with subarachnoid hemorrhage S Kifer Macedo, N Ferreira Bastos, J Flores Paz, T De Carvalho Pessamilio, R Barbosa Castro, M Rodrigues Lacerda Hospital São José do Avaí, Itaperuna, Brazil Critical Care 2010, 14(Suppl 1):P346 (doi: 10.1186/cc8578) Introduction Sequential Organ Failure Assessment (SOFA) was originally created for sepsis, but their quality is now used in other medical conditions. Therefore, we add some criteria to the index to assess patients with subarachnoid hemorrhage. Methods Informed consent for each patient/family; APACHE II (criteria for admission) and SOFA weekly, serum glucose, lactate, calcium, sodium and magnesium; and measurement of axillary temperature and diuresis hourly as the additional prognostic index SOFA. The study enrolled 103 patients diagnosed with SAH, conirmed by computed tomography. These patients were divided into two groups according to their development in the ICU: Group I – patients who had good evolution (out of ICU), and Group II – patients who progressed to death in the ICU. Results Among 103 patients, 74 (71.84%) were female and 29 (28.16%) were male. The APACHE II for admission varied from 2 to 34, with an average of 15.5. The spent time maximum in the ICU was 49 days (two patients). Group I had 64 patients (62.14%) and the 39 remaining patients (37.86%) were classiied as Group II. See Figures 1 and 2. Conclusions We can conclude that the group with patients with SAH is predominantly female (74:29). The APACHE II in Group I was 10.9, while Group II was 17.9. Regarding the criteria used to assess patients with SAH was observed that the only criterion which showed statistical signiicance in the prediction of death was the serum sodium (P = 0.002). The other S117 criteria evaluated did not have statistical signiicance in predicting the prognosis of patients. Reference 1. Knobel E: Condutas no Paciente Grave. Volume 1. 3rd edition. São Paulo: Editora Atheneu; 2006:871-883. P347 Cardiac output augmentation with luid resuscitation improves brain tissue oxygenation after severe brain injury R Helbok, P Kurtz, J Claassen, J Schmidt, L Fernadez, R Stuart, ES Connoly, N Badjatia, SA Mayer, K Lee Columbia University Medical Center, New York, USA Critical Care 2010, 14(Suppl 1):P347 (doi: 10.1186/cc8579) Introduction The objective of this study was to investigate the relationship between cardiac output response to a luid challenge and changes in brain tissue oxygen pressure (PbtO2) in patients with severe brain injury. Methods Prospective observational study conducted in a neurological ICU in a university hospital. Seventy-eight luid challenges were administered to 17 consecutive comatose patients that underwent multimodality monitoring of cardiac output, intracranial pressure (ICP), and PbtO2. The relationship between cardiac output and PbtO2 was analyzed with logistic regression utilizing GEE with an exchangeable correlation structure. Results Of the 78 luid boluses analyzed, 34 (44%) resulted in a ≥10% increase in cardiac output. Median absolute (+5.4 vs +0.7 mmHg) and percentage (20% vs 3%) changes in PbtO2 were greater in cardiac output responders than in nonresponders within 30 minutes after the end of the luid bolus infusion. In a multivariable model, a cardiac output response was independently associated with PbtO2 response (adjusted odds ratio 15.4, 95% CI 1.9 to 122.0, P = 0.01) after adjusting for mean arterial pressure, Figure 1 (abstract P347). Figure 1 (abstract P346). Figure 2 (abstract P346). Figure 2 (abstract P347). Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 intracranial pressure and end-tidal CO2. Stroke volume variation showed a good ability to predict cardiac output response with an area under the ROC curve of 0.85 with a best cutof value of 8%. See Figures 1 and 2. Conclusions Bolus luid resuscitation resulting in augmentation of cardiac output can improve cerebral oxygenation after severe brain injury. P348 Multicentre experience of using ICM+ for investigations of cerebrovascular dynamics with near-infrared spectroscopy P Smielewski1, M Czosnyka1, C Zweifel1, K Brady2, C Hogue2, L Steiner3, P Hutchinson1, D Mennon1, J Pickard1 1 University of Cambridge, UK; 2Johns Hopkins Hospital, Baltimore, MD, USA; 3 University Hospital, Basel, Switzerland Critical Care 2010, 14(Suppl 1):P348 (doi: 10.1186/cc8580) Introduction ICM+ software encapsulates our 20 years’ experience in brain monitoring. It collects data from a variety of bedside monitors and produces time trends of parameters deined using conigurable mathematical formulae. To date it is being used in nearly 40 clinical research centres worldwide. We present its application for continuous monitoring of cerebral autoregulation using near-infrared spectroscopy (NIRS). Methods Data from multiple bedside monitors are processed by ICM+ in real time using a large selection of signal processing methods. These include various time and frequency domain analysis functions as well as fully customisable digital ilters. The inal results are displayed in a variety of ways including simple time trends, as well as time window based histograms, cross histograms, correlations, and so forth. All this allows complex information from bedside monitors to be summarized in a concise fashion and presented to medical and nursing staf in a simple way that alerts them to the development of various pathological processes. Results One hundred and ifty patients monitored continuously with NIRS, arterial blood pressure (ABP) and intracranial pressure (ICP), where available, were included in this study. There were 40 severely headinjured adult patients, 27 SAH patients (NCCU, Cambridge); 60 patients undergoing cardiopulmonary bypass (John Hopkins Hospital, Baltimore) and 23 patients with sepsis (University Hospital, Basel). In addition, MCA low velocity (FV) was monitored intermittently using transcranial Doppler. FV-derived and ICP-derived pressure reactivity indices (PRx, Mx), as well as NIRS-derived reactivity indices (Cox, Tox, Thx) were calculated and showed signiicant correlation with each other in all cohorts. Errorbar charts showing reactivity index PRx versus CPP (optimal CPP chart) as well as similar curves for NIRS indices versus CPP and ABP were also demonstrated. Conclusions ICM+ software is proving to be a very useful tool for enhancing the battery of available means for monitoring cerebral vasoreactivity and potentially facilitating autoregulation guided therapy. Complexity of data analysis is also hidden inside loadable proiles, thus allowing investigators to take full advantage of validated protocols including advanced processing formulas. S118 position after induction during DLV, in the lateral decubitus position during DLV and every 15 minutes during OLV. Results Satcereb increased signiicantly when DLV was started with FiO2 1.0 and remained stable during the course of the study. When ventilation was changed from DLV to OLV, no signiicant change was observed. A signiicant decrease of cerebral oxygen saturation was found compared with the value observed during DLV in the lateral decubitus at the time point of 60 minutes after the start of OLV. No signiicant changes in the MCAV were observed throughout the course of the thoracic surgical procedure. Conclusions OLV does not result in clinically relevant decreases in cerebral blood low and cerebral oxygen saturation during application of lung-protective ventilation if normocapnia is maintained. P350 Factors afecting the transient hyperaemic response test of the cerebral autoregulation MS Sitina, V Cerny University Hospital, Hradec Kralove, Czech Republic Critical Care 2010, 14(Suppl 1):P350 (doi: 10.1186/cc8582) Introduction The transient compression of the internal carotid artery (ICA) results in dilatation of cerebral arterioles by efect of autoregulation. In the THR test, the increase in middle cerebral artery (MCA) blood low immediately after release of transient compression of the ICA is measured, which is proportional to cerebral autoregulation. The aim of the study was to determine the signiicance of several factors of the test – blood low inertia (acceleration), dimensions (length and radius) of ICA, patency of the Circle of Willis (WC), and asynchrony between release of ICA compression and arterial pressure pulsations (phase shift). Methods We constructed a mathematical model of the elements included in the THR test and simulated, using various parameters, blood low in cerebral vessels and the increase in low velocity in the MCA after release of ICA compression. We simulated two extreme situations – a perfectly patent (all aferent and eferent arteries meet in one point) and a completely isolated Circle of Willis (ICA bifurcates into only the anterior and middle cerebral arteries). The series of ordinary diferential equations describing the THR test was solved by MATLAB R2008a. The solution assumed an absence of autoregulation (efect of studied factors is independent of autoregulation) and the rigidity of all vessels. Results The efects of acceleration (inertia), dimensions of ICA and patency of WC are negligible. The efect of phase shift (Figure 1) can signiicantly decrease the immediate post-release MCA low, which can entirely nullify the increase in post-release MCA low caused by autoregulation. Conclusions The efect of phase shift can signiicantly alter the results of the THR test. For practical purposes we recommend calculation of THR test parameters from the second peak of post-release MCA low, or using the highest post-release MCA low from several THR tests. P349 Cerebral oxygen saturation and cerebral blood low are relatively stable during single-lung ventilation, if normocapnia is maintained T Végh, S Szatmári, M Juhász, I László, I Takács, B Fülesdi University of Debrecen, Hungary Critical Care 2010, 14(Suppl 1):P349 (doi: 10.1186/cc8581) Introduction Previously a report has suggested that administration of a lung-protective strategy for one-lung ventilation (OLV) results in oxygen desaturation of the brain parenchyma. The aim of the present work was to test whether the maintenance of normocapnia during a protective OLV strategy results in alteration of cerebral blood low and cerebral oxygen saturation. Methods Data were obtained from 15 patients undergoing thoracic surgery and necessitating OLV of more than 1 hour. Cerebral oxygen saturation (Satcereb) was continuously monitored by the INVOS 5100C Cerebral Oxymeter System along with measurement of cerebral blood low velocity (MCAV) by transcranial Doppler sonography. Arterial blood samples were taken for blood gas analysis in the awake state, in the supine Figure 1 (abstract P350). Dependence of THRR on phase shift. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P351 Infection associated with the external ventricular derivation catheter: preliminary data S Kifer Macedo, CM Primo de Siqueira, S Boechat Primo de Siqueira, B Almeida Simão Da Mata, S Ferrari Salles, L Reggiani de Almeida, F Oliva Battisti Hospital São José do Avaí, Itaperuna, Brazil Critical Care 2010, 14(Suppl 1):P351 (doi: 10.1186/cc8583) Introduction The purpose of this study was to evaluate the total drainage time, the risk of infection associated with external ventricular derivation (EVD) and the most prevalent infective agent during the use of EVD drainage in patients on the ICU. Methods During 15 months (8 August 2008 to 28 October 2009), all patients on the neurovascular ICU who had an EVD inserted were studied prospectively. Each 3 days we analysed cerebral spinal luid (CSF) samples for cell count, biochemistry and sputum. CSF cultures were evaluated three times a week combined with an antibiogram. Not included were the cultures that persisted with the same result (agent), considering only a new agent until negativity of the culture and clinical resolution. We excluded patients admitted with EVD from another hospital. Results Were included 46 patients, in which were obtained a total number of 66 EVDs. Thirty-ive EVDs (53,03%) had associated ICP monitoring. A total 65.21% of patients were female. The mortality of patients was 36.95% (17 deaths). Among infected catheters, infection was conirmed in approximately 7.1 days after the EVD was installed. However, the catheters discharged with negative culture or without growth of a new agent remained approximately 6.15 days on the brain ventricle of patients. Registered were 20 positive bacteriological cultures of CSF (30.30%) among the total EVDs. The most prevalent organisms were Acinetobacter baumanii on nine cultures (45%), Pseudomonas aeruginosa on six cultures (30%), Serratia rubidaea on one culture (5%), Streptococcus oralis on one culture (5%), Klebsiella ornithinolytica on one culture (5%), Estailococcus coagulase negative on one culture(5%), Stenotrophonas maltophylia on one culture (5%). Conclusions Some previous studies show a substitution from positive Gram agents to negative Gram agents on infections associated with EVD. The study has shown a prevalence of P. aeruginosa and A. baumanii on infection associated with the EVD catheter, which are also more prevalent in the ICU environment. This study reinforces that, in case of suspected CNS infection associated with catheter EVD (meningitis, ventriculitis, or abscess), we can start empirical antimicrobial coverage for Gram-negative infections, including intraventricular administration (intrathecal) as Polymixin B. P352 fMRI default mode connectivity in vegetative state and locked-in syndrome patients A Soddu1, A Vanhaudenhuyse1, M Boly1, MA Bruno1, L Tshibanda2, C Phillips1, M Stanziano3, S Ovadia Caro4, Y Nir5, P Maquet1, M Papa3, R Malach4, Q Noirhomme1, S Laureys1 1 Coma Science Group, Liege, Belgium; 2Neurology Department, CHU Sart Tilman Hospital, University of Liège, Belgium; 3Pubblica Clinica e Preventiva, Second University of Naples, Italy; 4Department of Neurobiology, Weizmann Institute of Science, Rehovot, Israel; 5Department of Psychiatry, University of Wisconsin, Madison, WI, USA Critical Care 2010, 14(Suppl 1):P352 (doi: 10.1186/cc8584) Introduction The aim of this study is to assess fMRI resting-state cerebral connectivity in vegetative state and locked-in syndrome patients by means of a user-independent method. Resting baseline (or default mode) activity is thought to be related to awareness of the internal world (that is, mind wandering, and so forth) and encompasses posterior cingulate/precuneal, anterior cingulate/mesiofrontal and posterior lateral parietal cortices. Methods We here present a novel clinical application for a userindependent default mode network analysis. Resting state data were acquired for seven vegetative state patients (age range 16 to 87 years), one locked-in syndrome patient (aged 24 years) and seven healthy subjects (25 to 65 years). Patients’ diagnosis was based on Coma Recovery Scale assessment prior and following scanning. Data were pre-processed and analyzed using independent component analysis as implemented in Brain Voyager. Connectivity studies employed 13 target regions of interest S119 deined on an average default mode map calculated from an independent dataset of 20 controls (21 to 60 years). Resting state connectivity was assessed by calculating the number of functional connections within the default mode map for each subject. Next, Student t tests compared patients with controls at the group level (P <0.05). Results Compared with controls, vegetative patients showed a lower total number of edges (that is, connections; 24 ± 4, range 19 to 31 and 13 ± 3, range 8 to 15, P <0.001) and less functional connections with the precuneus (6 ± 1 and 2 ± 2; P <0.001). The default mode network shows a reduced connectivity in vegetative patients as compared with controls mainly between the precuneus and medial prefrontal cortex ventral. Finally, for the locked-in syndrome patient the connectivity graph counted 21 total number of efective connections and ive efective connections with the precuneus, which was not signiicantly diferent from healthy controls. Conclusions The connectivity study showed no overlap between the number of efective connections or edges in vegetative state patients and in controls. Connectivity graph analysis identiied anterior–posterior midline disconnections in the vegetative state, in line with previous studies emphasizing the critical role of the precuneus/PCC and mesiofrontal cortices in the emergence of conscious awareness. P353 Incidence of cerebral salt wasting syndrome: comparison in subarachnoid haemorrhagic compared with head trauma FD Di Sacco1, GB Bernardeschi1, AD Demi1, CC Conversano2, EL Lensi2, FF Forfori1, FG Giunta1 1 Pisa University, Pisa, Italy; 2Siena University, Pisa, Italy Critical Care 2010, 14(Suppl 1):P353 (doi: 10.1186/cc8585) Introduction Cerebral salt wasting syndrome (CSWS) is characterized by severe hyponatriemia, caused by the reduction of sodium reabsorption at the level of proximal tubule, with associated polyuria and hypovolemia. For decades, this syndrome was confused with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH), but in CSWS the antidiuretic hormone is physiologically secreted. The only way to make a diference in the diagnosis is the assessment of the extracellular volume, not easily measurable in critical care patients. We designed this study to assess the frequency, the onset and the duration of the symptoms of CSWS in patients hospitalized in post-neurosurgery critical care. Methods In the 2-year period 2008 to 2009 in the post-neurosurgery ICU, 131 patients were studied retrospectively; 63 patients had subarachnoid haemorrhage (SAH) caused by the rupture of a cerebral aneurysm and 68 patients had severe head trauma (HI). CSWS diagnosis was done evaluating sodiemia, serum osmolality, sodiuria 24 hours and central venous pressure. The time from the onset of hyponatriemia during ICU stay and duration of symptoms was also evaluated. Results Patients developed CSWS in 12.7%, of whom 7.9% within 1 week from admission and 4.8% after. Among the patients with HI, 5.8% developed CSWS, of whom 2.9% within the irst week while the other 2.9% after. CSWS symptoms lasted for more than 1 week in 11.1% of patients with SAH, and less only in 1.6%, while in HI the symptoms lasted less than 1 week in 2.9% and more than 1 week in 2.9% of patients. Conclusions Diferential diagnosis of ICU hyponatriemia is important in determining patient outcome. CSWS treatment required an appropriate luid and salt replacement to normalize hydroelectrolytic balance. CSWS has a diferent distribution in patients with subarachnoid haemorrhage compared with traumatic head injury. Furthermore, the syndrome starts earlier and lasts longer in SAH compared with HI. P354 Sodium dysbalances in neurointensive care: results of a 5-year prospective study V Spatenkova1, A Kazda2, P Suchomel1 1 Regional Hospital, Liberec, Czech Republic; 21st Faculty of Medicine, Charles University, Prague, Czech Republic Critical Care 2010, 14(Suppl 1):P354 (doi: 10.1186/cc8586) Introduction Sodium dysbalances represent important complications in neurointensive care. The aim of this study was to analyse sodium Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 dysbalances and their relationship to outcome in the neurologic– neurosurgical care unit (NNICU) over a period of 5 years. Methods We prospectively evaluated patients with brain diseases, who developed serum sodium below 135 mmol/l (hyponatremia) or above 150 mmol/l (hypernatremia). We compared the incidence of cerebral complications, Glasgow Outcome Scale upon discharge from the NNICU and mortality in the NNICU between these two groups. Results In the 5-year observation period, serum sodium dysbalances occurred in 378 (24%) patients. The majority of them had hyponatremia (245 patients, 65%); hypernatremia was less frequent, in 133 (35%) patients. Hypernatremic patients stayed in the NNICU longer (P = 0.035), onset of hypernatremia arose in patients with signiicantly lower Glasgow Coma Scale (P = 0.001). These patients had more cerebral complications (P <0.001), worse Glasgow Outcome Scale upon discharge from the NNICU (P <0.001), higher mortality in the NNICU (P = 0.003) and higher incidence of pulmonary edema (P = 0.021). They received more antiedematic therapy (P <0.001) and diuretics (P <0.001). On the other hand, hyponatremia was more frequent upon entry to the NNICU (P <0.001) and arose later after brain damage (P <0.001) in comparison with hypernatremia. Conclusions In neurointensive care, hypernatremia was a prognostically more serious and less frequent sodium dysbalance than hyponatremia. P355 Impact of hypernatremia on patients with severe traumatic brain injury M Shehata, D Ragab, M Khaled, M Hegazy, A Hussein, H Khaled Cairo University, Cairo, Egypt Critical Care 2010, 14(Suppl 1):P355 (doi: 10.1186/cc8587) Introduction Hypernatremia is frequently encountered in the neurocritical ICU and its efect can badly afect mortality. The objective of this study was to verify whether the occurrence of hypernatremia during the ICU stay increases the risk of death in patients with severe traumatic brain injury (TBI). Methods Randomized prospective study of 100 patients with TBI in neurocritical care units at Cairo University Hospital. Hypernatremia is deined as serum sodium above 145 mmol/l. The major outcome was death in the ICU. Logistic regression models were used to assess independent factors that could afect patients’ mortality including hypernatremia, age, desmopressin and Glasgow Coma Score. Results We included in the study 100 TBI patients (mean age 35.8 ± 21.3 years); males 86%. Extradural hematoma (EDH) was documented in 27 patients (27%), subarachnoid (SAH) in 20 patients (20%), intracerebral (ICH) in 19 patients (19%), cerebral contusion in 17 patients (17%), brain oedema in 15 patients (15%), and subdural hematoma in two patients (2%). Glasgow Coma Scores (range 3 to 10); 60 patients were mechanically ventilated; 10% were diabetic and 22% were hypertensive. Hypernatremia was documented in 40 patients (40%) of the total TBI patients. The total inhospital mortality was 36/100 (36%), 10 of them had normal sodium levels all through their in-hospital course and 26 patients were hypernatremic. After adjustment for the baseline risk, the incidence of hypernatremia over the course of the ICU stay was signiicantly related to increased mortality (hazard ratio 3.2 (P = 0.0001)). However, there was positive correlation between serum sodium levels and duration of the ICU stay (Spearman correlation coeicient 0.5 and P = 0.002). Conclusions Hypernatremia in patients with severe TBI is associated with an increased risk of death, and a longer ICU stay. This association is independent of other outcome predictors including age and Glasgow Coma Score. Strategies to prevent hypernatremia in neurocritical ICUs should be encouraged. Reference 1. Adrogué HJ, Madias NE: N Engl J Med 2000, 342:1493-1499. S120 P356 Prevalence and clinical setting of SIADH in neurosurgery: comparison between subarachnoid haemorrhage and head trauma FD Di Sacco1, AD Demi1, GB Bernardeschi1, CC Conversano2, EL Lensi2, FF Forfori1, FG Giunta1 1 Pisa University, Pisa, Italy; 2Siena University, Pisa, Italy Critical Care 2010, 14(Suppl 1):P356 (doi: 10.1186/cc8588) Introduction The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is a very important disorder in neurosurgery, and it is one of the most common causes of hyponatriemia in acute brain injury. SIADH should be suspected in any patient with hyponatremia, hypoosmolarity, urine osmolality above 100 mosmol/kg H2O, concentration of sodium in the urine usually above 40 mEq/l, and clinical euvolemia. This study was designed to assess the frequency of this syndrome in the postneurosurgery ICU, the time of onset and the duration of symptoms. Methods In a 2-year period (2008 to 2009), 131 patients, hospitalized in a post-neurosurgery ICU for TBI or ESA were retrospectively studied. According to the previous deinition, 63 patients had subarachnoid haemorrhage (SAH) from rupture of aneurysm and 68 patients had severe head trauma (HI). Diagnosis of SIADH was conirmed by pH, sodiemia, plasmatic and urinary osmolality, sodiuria of 24 hours and central venous pressure. The time to onset of hyponatremia during hospitalization in ICU was evaluated, and its duration despite adequate treatment (luid restriction and eventually hypertonic saline). Results Patients developed SIADH in 5.34%. Three patients had a subarachnoid hemorrhage and four patients were hospitalized for head trauma. The onset of this syndrome was within the irst week in two patients with SAH and in only one with traumatic head injury. With regard to the duration of symptoms, SIADH lasted more than a week in the most of patients, with no diferences between the two groups. Conclusions In patients with hyponatriemia, an adequate diagnosis of SIADH is very important in order to improve the outcome, especially in the ICU. In this study we found no diferences in the SIADH setting between patients with subarachnoid haemorrhage and in patients with traumatic head injury. But, owing to the small number of patients with this syndrome enrolled, this trend has to be conirmed in further studies. P357 Risk factors for venous thromboembolism in Japanese patients with severe blunt trauma Y Masuda, N Saito, K Mashiko Chiba Hokusou Hospital, Nippon Medical School, Chiba, Japan Critical Care 2010, 14(Suppl 1):P357 (doi: 10.1186/cc8589) Introduction Venous thromboembolism (VTE) is a common complication after major trauma, and has a high rate of morbidity and mortality. However, racial disparities in incidence of as well as risk factors for VTE exist between Asian and western populations. The risks for VTE after major trauma in Japanese patients remain unknown. Our objective was to identify risk factors for VTE after severe blunt trauma in Japanese patients. Methods We conducted a prospective cohort study to investigate risk factors for VTE in patients who were admitted to our hospital because of blunt trauma between April 2008 and July 2009. We performed VTE screening by duplex ultrasonographic scan for all blunt trauma patients who had bed rest ≥3 days and recorded Injury Severity Score (ISS) ≥9 within the irst 7 days after admission. We initiated pharmacologic VTE prophylaxis, irst with low-dose unfractionated heparin and then with lowdose warfarin. The chi-square test was used for categorical variables and the t test for continuous variables. Results A total of 101 patients (69 males, 32 females) with blunt trauma (median age 48.48 ± 20.5 (SD) years and mean ISS of 20.0 ± 10.2) were enrolled in this study. Pharmacologic VTE prophylaxis was initiated in 61 of these patients (60.4%). Ten patients (10.0%) experienced VTE. Univariate analysis of potential factors for VTE identiied signiicant associations between thrombosis and the following factors: transfusion, major surgery, the presence of a central venous line in the femoral vein, and direct traction of lower limb (P <0.05 for all these factors). Conclusions The incidence of VTE in Japanese patients with severe blunt trauma was 10.0%. These risk factors have all been given in the results above. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S121 P358 Safety of heparin prophylaxis for venous thromboembolism in patients with neurotrauma G Puri, P Joseph Postgraduate Institute of Medical Education and Research, Chandigarh, India Critical Care 2010, 14(Suppl 1):P358 (doi: 10.1186/cc8590) Introduction Patients with neurotrauma are at high risk for VTE. The safety of early anticoagulation for neurotrauma has not been established. Our study was based on the hypothesis that unfractionated heparin can be safely administered to most patients with neurotrauma for VTE prophylaxis. Methods Prospective, single-cohort, observational study. All adult patients with neurotrauma admitted to a tertiary care teaching hospital in India from March to December 2007 received unfractionated heparin beginning approximately 24 hours after hospital admission until discharge. Brain CT scans were performed at admission, 24 hours after admission, and at variable intervals thereafter based on clinical course. Patients were excluded for coagulopathy, expected brain death or discharge within 48 hours. Complications of heparin prophylaxis were deined as expansion of existing intracranial haemorrhage or development of a new haemorrhagic lesion on follow-up CT after beginning heparin use. Results Twenty-one of 57 (36.8%) adult neurotrauma patients were eligible for heparin therapy. Their distribution of CT indings is presented in Table 1. Serial CT scan had progression of lesion in four of the 26 patients not on heparin therapy and in two of the 21 patients on heparin (P >0.05). No diference in complications between patients with ICH on heparin (2/14) and not on heparin (1/13) were identiied (P >0.05). The mortality in the heparin group was 3/21(14.3%). Both the patients who developed worsening of CT indings after initiation of heparin therapy survived hospitalization. None of the patients sufered from DVT. Table 1 (abstract 358). Distribution of CT indings and heparin therapy CT Normal DBE Contusion Hge # Skull No heparin Heparin 8 8 13 27 1 0 3 3 14 1 Conclusions Heparin can be safely used for VTE prophylaxis in patients with head injury when started 24 hours after hospital admission. P359 Prevalence and incidence of proximal deep vein thrombosis in critically ill patients A Panitchote, W Chaiyasoot, C Permpikul Mahidol University, Bangkok, Thailand Critical Care 2010, 14(Suppl 1):P359 (doi: 10.1186/cc8591) Introduction The epidemiology of DVT in critically ill medical patients has not been studied in Thailand. The aim of this study was to assess the prevalence and incidence rate of proximal DVT in these patients and to determine the factors associated with the development of this condition. Methods A single-center, prospective observational study was performed in critically ill medical patients who developed sepsis or new organ failure requiring organ support. DVT was detected by ultrasonography with color Doppler imaging performed within 48 hours after the patients met the inclusion criteria, and serial studies at days 7, 14 and 28 (or earlier if clinically indicated) were carried out. Results Of the 170 patients, 87 were male (51.2%). The mean age was 59.95 years (range 18 to 94), and the mean APACHE II score was 21.34 (range 4 to 42). Acute respiratory failure and sepsis were the leading diagnoses. Prevalence and incidence of proximal DVT were 14.1% (95% CI 9.6 to 20.15) and 8.82% (95% CI 5.4 to 14.0), respectively. Univariate analysis of factors associated with DVT showed female sex (P = 0.017), age ≥50 years (P = 0.017), renal replacement therapy (P = 0.005) and femoral venous catheter (P = 0.002) while multivariate analysis showed female sex (P = 0.007; OR = 4.43, 95% CI 1.5 to 13.08), age ≥50 years (P = 0.027; OR = 6.12, 95% CI 1.23 to 30.49), femoral venous catheter (P <0.001; OR = 11.77, 95% CI 3.11 to 44.53) and the absence of platelet transfusion (P = 0.015; OR = 0.056, 95% CI 0.005 to 0.58). Clinical probability at the irst 48 hours but not at days 7, 14 and 28 was strongly correlated with the development of proximal DVT. The duration of mechanical ventilation, the hospital length of stay and the ICU mortality were not afected by the presence of DVT. Conclusions Proximal DVT of lower extremities in critically ill medical Thai patients are not uncommon. Thromboprophylaxis study is needed in order to investigate the risk and beneit. References 1. 2. Geerts WH, et al.: Prevention of venous thromboembolism: the Eighth ACCP Conference on Antithrombotic and Thrombolytic therapy. Chest 2008, 133(Suppl):381S-453S. Cook DJ, et al.: Deep venous thrombosis in medical–surgical ICU patients: prevalence, incidence and risk factors. Crit Care Med 2005, 33:1565-1571. P360 Trauma patients with prophylactic IVC ilter and chemical prophylaxis: a descriptive study MM Perreault, J Yan, A Karamaoun, E Villeneuve, T Razek The Montreal General Hospital, Montreal, Canada Critical Care 2010, 14(Suppl 1):P360 (doi: 10.1186/cc8592) Introduction Trauma patients at high risk of thrombosis and bleeding often have a retrievable inferior vena cava ilter (IVCF) inserted prophylactically shortly after admission for the prevention of pulmonary embolism. Despite their increasing use in trauma, controversy exists regarding patient selection, beneits and safety. In addition, chemical prophylaxis should be initiated as soon as determined to be safe to do so. Limited data exist describing the use of chemical prophylaxis and the timing of it in relation to IVCF placement in this patient population. We aim to describe such use and timing in relation to IVCF placement. Methods All trauma patients with a retrievable prophylactic IVCF inserted over 3.5 years with an age ≥18 and an ISS ≥15 were enrolled into the descriptive study. Patients were identiied using the local trauma registry and data collected from the registry and patient chart. Results One hundred and three patients with a prophylactic IVCF are described. Mean age was 42.8 ± 17.9 years, 68% were male and they had a mean ISS of 38.6 ± 12. A total of 36.9% had ≥3 injuries. A total of 60.2% had an injury with maximum AIS score ≥5 and the type of injury associated with maximal AIS was head (53.4%), pelvic (19.4%), thoracic (15.5%) and spinal cord injury (11.7%). Shock was present on admission in 8.7% patients, 98.1% required ICU admission, 88.4% required intubation and 27.2% patients required ≥4 PRBC over the irst 24 hours. The retrievable IVCF was inserted prophylactically after a mean of 1.7 ± 1.9 days (range 0 to 9 days) of hospital admission. Chemical prophylaxis was initiated 5.7 ± 5.1 days after IVCF in 77.7% patients, and dalteparin or enoxaparin were the initial agents of choice in 93.8% while heparin was chosen in 6.2% of cases. The time from hospital admission to the start of chemical prophylaxis ranged from 6.3 to 8.5 days. Conclusions Chemical prophylaxis was initiated in the majority of trauma patients with an IVCF, albeit 22% still did not receive any. When administered, a low-molecular-weight heparin was selected. Although rapidly inserted after admission, there was considerable delay between insertion of IVCF and initiation of chemical prophylaxis. The reasons for this delay require further investigation. Reference 1. Kaufman JA, et al.: Guidelines for the use of retrievable and convertible vena cava ilters. Surg Obes Relat Dis 2006, 2:200-212. P361 Clinical signs and risk factors of acute deep vein thrombosis of lower extremities in patients after abdominal surgery for cancer: eiciency and safety of diferent types of anticoagulant therapy O Tarabrin1, V Suslov2, S Kalinchuk3, S Tarasenko1, V Grubnik1, S Shcherbakov1, D Gavrichenko3 1 Odessa Medical University, Odessa, Ukraine; 2The Institute of Urology, Kiev, Ukraine; 3Regional Clinical Hospital, Odessa, Ukraine Critical Care 2010, 14(Suppl 1):P361 (doi: 10.1186/cc8593) Introduction The background of our research was to conduct a retrospective analysis of clinical signs and risk factors for acute deep vein Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 thrombosis (ADVT) of lower extremities, and to compare the efectiveness and safety of therapy of LMWH bemiparin and UFH in patients after abdominal surgery for cancer. Methods For the period from 2008 to 2009 the diagnosis of ADVT was set for 362 patients, among them 179 (49.4%) men and 183 (50.6%) women. Among patients with ADTV with primary localization in ileofemoral and popliteal segments treated in the department of vascular surgery, senior persons more than 60 years old prevailed (63.9%). All patients with ADVT received therapy with anticoagulants. Bemiparin sodium was prescribed in 257 (70.9%) cases, UFH in 71 (19.6%) and in 34 (9.5%) others LMWH. We analysed eiciency and complications after antithrombotic therapy in a hospital period. A complete coagulation screen, activated clotting time, thromboelastography and low-frequency haemoviscoelastography (HVG) were performed to reveal coagulation disturbances. Results In 83.7% of cases the most frequent symptoms of disease are edema of an extremity (in 78.1%) and pain syndrome 74.7%, which at a monosymptomal variant (39.4% patients) are marked in 66.3% and 44.4% accordingly. The most frequent risk factors (RF) were prolonged (more than 8 days) immobilization and malignant tumors. Therapy of UFH and LMWH was efective enough (on average, a good result obtained in more than in 77% cases). Bemiparin treatment was related to considerably less hemorrhagic complications than treatment of UFH (P <0.05), which concerned all of types of such complications. Conclusions Treatment of with bemiparin as compared with UFH accompanied reduced frequency of all hemorrhagic complications by 2.1 times, serious 2.7 times and moderate 3.1 times. HVG is an efective pointof-care monitor for routine clinical practice and clinical research. P362 Multidrug sedation as a risk factor for deep vein thrombosis in the intensive care unit F Barbani1, L Tutino1, S Batacchi2, A Cecchi2, M Bonizzoli2, M Boddi3, G Zagli2, A Peris2 1 Postgraduate School of Anesthesia and Intensive Care, University of Florence, Italy; 2Careggi Teaching Hospital, Florence, Italy; 3Department of Critical Care Medicine and Surgery, University of Florence, Italy Critical Care 2010, 14(Suppl 1):P362 (doi: 10.1186/cc8594) Introduction Critically ill patients are at high risk for deep vein thrombosis (DVT). Among ICU DVT risk factors, the role of muscle relaxant (MR) has been clearly shown [1] but the possible inluence of sedative medications (SM) is still under debate. This study was aimed at investigating whether the use of diferent SM may afect DVT incidence in ICU patients. Methods We retrospectively enrolled all patients admitted to a mixed medical–surgical trauma ICU from January 2007 to August 2008 who showed a >72 hours length of stay and were >18 years old; exclusion criteria were DVT at admission and/or within the previous 6 months, thrombophilic proile, high haemorrhagic risk, admission from another ICU. For studying ICU lower limb DVT incidence, compressive ultrasonography (CUS) was performed by three trained ultrasonographers twice a week until discharge. SM and MR administration was registered daily: the drugs considered are presented in Figure 1. MR-treated patients were excluded from statistical analysis; the diference in SM administration in the No DVT group vs the DVT-positive group was assayed by chi-squared test. Results Over the period of study, 380 patients were enrolled. Lower limb DVT was diagnosed in 23 of 380 patients, with a DVT incidence of 6.05%. Figure 1 (abstract P362). Statistical analysis. S122 MRs were administered in 121 patients and they were associated with DVT incidence (P <0.001). Statistical analysis results performed on 259 patients are shown in Figure 1: none of the considered SM resulted to be associated with DVT incidence, nor sedation as a whole or the number of SM administered. Conclusions Our study conirms prior indings [1] on the MR role as a DVT risk factor. Nevertheless, SM administration in patients not treated with MR is not associated with increased DVT risk. References 1. J Thromb Haemost 2009. [Epub ahead of print. DOI: 10.1111/j.1538-7836.2009.03664.x] P363 New method diagnostics for coagulation disorders after surgery O Tarabrin1, V Suslov2, V Grubnik1, S Kalinchuk3, P Pustovoyt3, S Shcherbakov1, D Gavrichenko3 1 Odessa Medical University, Odessa, Ukraine; 2The Institute of Urology, Odessa, Ukraine; 3Regional Clinical Hospital, Odessa, Ukraine Critical Care 2010, 14(Suppl 1):P363 (doi: 10.1186/cc8595) Introduction Despite the evidence of perioperative hypercoagulability in cancer patients, there are no consistent data evaluating the extent, duration, and speciic contribution of platelets and procoagulatory proteins by in vitro testing. This study compared eicacy of haemoviscoelastography versus thromboelastography for monitoring of coagulation imbalance. Methods Two hundred and forty-one patients undergoing surgery for abdominal cancer were examined for the eicacy of a variety of coagulation tests. A complete coagulation screening, thromboelastography (TEG) and haemoviscoelastography (HVG) were performed before and at the end of surgery. Results We calculated the elastic shear modulus of standard MA (Gt) and HVG MA (Gh), which relect the total clot strength and procoagulatory protein component, respectively. The diference was an estimate of the platelet component (Gp). There was a 16% perioperative increase of standard MA, corresponding to a 51% increase of Gt (P <0.05) and a 79% to 87% contribution of the calculated Gp to Gt. We conclude that serial standard thromboelastography and the HVG viscoelastic test may reveal the independent contribution of platelets and procoagulatory proteins to clot strength. Using multiple linear regression, all coagulation, TEG and HVG variabilities were used to model postoperative hypercoagulation. Results showed that some components of the TEG failed to identify hypercoagulation (r <0.2, P >0.75). All components of the HVG test relect postoperative coagulopathies. Conclusions Hypercoagulability is not relected completely by standard coagulation monitoring and TEG, and seems to be predominantly caused by increased platelet reactivity. HVG provides a fast and easy-toperform bedside test to quantify in vitro coagulation, and may be useful in determining the coagulation status of cancer patients perioperatively. P364 Thrombocytopenia in surgical ICU patients O Yhiaoui, M Metref Military Hospital, Algiers, Algeria Critical Care 2010, 14(Suppl 1):P364 (doi: 10.1186/cc8596) Introduction The aim was to study the incidence, the etiology and to assess the severity of thrombocytopenia in surgical ICU (SICU) patients admitted to the central army hospital of Algiers (Algeria). Methods We conducted a retrospective study; all admitted patients during the year 2008 were enrolled in the study (351 patients). All charts were reviewed and diferent hemograms recorded from admission until discharge. One hundred and ifty-three thrombocytopenia cases deined as a platelet count (plt) <150 x 109 were reported (43.6%). Results Among 351 patients (227 survivors, 124 died), 153 developed thrombocytopenia, 96 males and 57 females. The onset of thrombocytopenia was for the majority of patients (98%) at 24 to 72 hours after ICU admission. Only 26% were severe (plt <50 x 109) and 3% <20 x 109). The etiopathology is multifactorial and diicult to obtain precisely: 77% Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 of cases were hemodynamically unstable multitrauma patients (with or without ARDS and fat embolism), and necessitated volume and blood product administration through an intravascular device; sepsis was present in 47% of cases; disseminated intravascular coagulopathy in 33%; and ive thrombocytopenia cases were related to drug administration with late onset after the 5th day. Reported mortality was 57% (P <10–6) compared with the overall mortality (35.3%), related to the severity of underlying diseases and the associated co-morbidities. Conclusions Thrombocytopenia is frequent among chirurgical patients, especially multitrauma patients with cardiovascular instability where aggressive volume and blood product administration is needed. P365 Platelet count as a prognostic marker in intensive care A Mackay, J Erskine, K Connor, M McCusker, S Noble Victoria Inirmary, Glasgow, UK Critical Care 2010, 14(Suppl 1):P365 (doi: 10.1186/cc8597) Introduction Thrombocytopenia is a common occurrence in the critically ill population [1]. We aimed to determine the incidence, severity and prognosis of thrombocytopenia in our ICU. Methods A retrospective laboratory result review of 330 consecutive admissions to the Victoria Inirmary ICU was undertaken. Demographics, APACHE II score and outcome data were retrieved from the Ward Watcher system in the ICU. We compared survivors’ and nonsurvivors’ platelet levels on admission to the ICU and the trough level in the ICU and looked at correlation with the length of stay and duration of mechanical ventilation. Data were analysed using Student’s t test, Pearson correlation coeicient and chi-squared test where appropriate. Results Complete data were available for 274 patients. Population demographics were as follows – 61.3% male, mean age 56.3 ± 2.1 years, median APACHE II 20 (IQR 15 to 27), crude ICU mortality 25.6% and mean length of stay 5.2 ± 0.7 days. Incidence of thrombocytopenia (platelet count <150 x 109/l) was 29.8% on admission to the ICU, increasing to 46.9% when considering the entire ICU stay. Comparing survivors and nonsurvivors, nonsurvivors had a lower trough platelet count (140 x 109/l vs 181 x 109/l, P = 0.005). Patients with platelet counts less than 50 x 109/l have the highest mortality (45.7% vs 27.6%, P = 0.006). Platelet data were used to construct an ROC curve, demonstrating an area under the curve of 0.66, P <0.001. Platelet count correlated negatively with APACHE II (r = –0.20, P <0.001) but did not correlate signiicantly with length of stay or duration of mechanical ventilation. Conclusions Thrombocytopenia occurs in 47% of our ICU patients. It correlates signiicantly with severity of illness as measured by APACHE II and decreasing platelet count correlates with increasing mortality, with the highest mortality in those with a trough ICU platelet count of less than 50 x 109/l. The ROC characteristics also demonstrate that the platelet count is a useful predictor of mortality. Reference 1. Strauss R, et al.: Newly developed thrombocytopenia in medical intensive care patients. Crit Care 2000, 4(Suppl 1):P23. P366 Evaluation of the particle immunoiltration anti-platelet factor 4 rapid assay in MICU patients with thrombocytopenia DM Andrews, DH Kett, Y Fajardo Aquino, GF Cubillos, AS Castelbalnco, DL Seckinger University of Miami/Jackson Memorial Hospital, Miami, FL, USA Critical Care 2010, 14(Suppl 1):P366 (doi: 10.1186/cc8598) Introduction Heparin-induced thrombocytopenia (HIT) is a lifethreatening and limb-threatening, immune-mediated, prothrombotic disease resulting from an interaction between heparin and platelet factor 4 (PF4). Due to the many causes of thrombocytopenia in critically ill patients, the diagnosis of HIT is diicult, requiring both a high clinical suspicion and conirmatory testing. The ELISA test is the most commonly performed method to detect anti-PF4 antibodies; however, the ELISA results generally take one or more days to report. The particle immunoiltration assay (PIFA) test has the advantage of being done rapidly; with results generally available within 1 hour. S123 Methods Starting in July 2009, patients in our MICU were screened daily for thrombocytopenia; deined as either a platelet count that decreased by at least 30% from baseline or an absolute platelet count less than 150,000. Patients with thrombocytopenia underwent both PIFA and GTI ELISA testing for anti-PF4 antibodies. PIFA is a qualitative test reporting results as positive or negative. The GTI ELISA test reports an optical density (OD), with an OD greater than 0.40 considered positive. Patients were followed through hospitalization. Results One hundred and thirty-eight patients were admitted to the MICU, with 47 developing thrombocytopenia. The PIFA results were negative in 22 patients, positive in 21 patients and inconclusive in four patients. For all patients with a negative PIFA result, the GTI ELISA test was negative. All four inconclusive PIFA tests had negative GTI ELISA tests. In patients with PIFA-positive results, two GTI ELISA tests were positive and 19 tests were negative. A serotonin release assay (SRA) was done in 13 patients with discordant PIFA/GTI ELISA tests, of which one SRA result was positive. None of the 47 patients with thrombocytopenia developed thrombotic complications. Conclusions Our analysis suggests that a negative PIFA test can quickly exclude the presence of anti-PF4 antibodies and therefore HIT as the cause of the thrombocytopenia. The PIFA test can be used as a rapid screening procedure for patients with possible HIT, and, when negative, decrease the exposure of thrombocytopenic MICU patients to alternative anticoagulation. The clinical signiicance of a positive PIFA test requires further study and must be evaluated in conjunction with clinical judgment and, as appropriate, additional testing for anti-PF4 antibodies. P367 Heparin-induced thrombocytopenia incidence in the ICU: preliminary results F Barbani1, R Marcucci2, S Degl’Innocenti3, A Rogolino2, S Fedi2, A Gori2, M Bonizzoli3, G Zagli3, A Peris3, R Abbate2 1 Postgraduate School of Anesthesia and Intensive Care, University of Florence, Italy; 2Department of Critical Care Medicine and Surgery, University of Florence, Italy; 3Careggi Teaching Hospital, Florence, Italy Critical Care 2010, 14(Suppl 1):P367 (doi: 10.1186/cc8599) Introduction Heparin-induced thrombocytopenia (HIT) is a lifethreatening and limb-threatening immune-mediated prothrombotic complication caused by heparinic drugs. The aim of this study was to evaluate the incidence of HIT in a mixed ICU population. Methods Patients admitted to the ICU of a regional referral center (Careggi Teaching Hospital, Florence, Italy) who underwent unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) administration were prospectively observed from October 2008. Exclusion criteria: haematological malignancy, platelet count <50,000/mm3 before anticoagulant treatment. After anticoagulant administration start, patients showing a fall of platelet count >50% or a nadir <150,000/mm3 were clinically evaluated with the 4T score (4Ts) [1]: cases with a 4Ts of at least 2 were investigated with the laboratory antigen assay, the ELISA. Positive tests underwent to a functional conirmation test, the heparin-induced platelet activation (HIPA) test [2]. Results Preliminary results refer to the period from the start to August 2009. Patients admitted to the ICU were 369; 327 enrolled for the study. Clinical evaluation with 4Ts was performed for 31 patients, 23 of 31 (74%) had a value of at least 2; eight of 23 were on UFH and the remaining 15 on LMWH. Potential etiologies of thrombocytopenia have been considered: 21 patients were septic, three were on extracorporeal membrane oxygenation, two were admitted to the ICU due to cardiogenic shock. The ELISA test resulted positive in three of 23 (13%) suspected HIT cases; none of the three cases resulted positive in the HIPA test, so HIT was excluded. The medium 4Ts of the 23 suspected HIT cases was 4.1 ± 1.7 whereas 4Ts did not difer between patients with positive and negative ELISA test. Conclusions HIT incidence in the ICU is extremely rare, with no cases shown in this study. HIT was suspected in 23 of 327 patients (7.03%), but the HIT incidence was 0.0%. ICU patients show numerous potential etiologies of thrombocytopenia and in this population sepsis was the most common. References 1. 2. Warkentin TE, et al.: Curr Hematol Rep 2003, 2:148-157. Greinacher A, et al.: Thromb Haemost 1991, 66:734-736. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S124 P368 Treatment of the coagulation deicit during extracorporeal circulation in a porcine model by a prothrombin complex concentrate F Kaspereit, S Hofman, I Pragst, G Dickneite CSL Behring, Marburg, Germany Critical Care 2010, 14(Suppl 1):P368 (doi: 10.1186/cc8600) P369 Fibrinogen in dilutional coagulopathy: a dose study in pigs J Martini1, S Maisch1, W Martini2, W Streif1, D Fries1 1 Medical University Innsbruck, Austria; 2US Army Institute for Surgical Research, San Antonio, TX, USA Critical Care 2010, 14(Suppl 1):P369 (doi: 10.1186/cc8601) Introduction Many procedures in cardiac surgery require extracorporeal circulation (EC). During EC, blood is pumped from a venous line to an oxygenator, cooled and infused back via an arterial line. This procedure is known to compromise the coagulation system, especially under prolonged hypothermia. The aim of the present study was to investigate the efects of EC and hypothermia on the coagulation system in a porcine model. The eicacy of a substitution therapy with a prothrombin complex concentrate (PCC) regarding normalization of coagulation and decrease in hemorrhage was evaluated. Methods A total of 17 male anesthetized pigs were included in the study. EC was performed in 12 animals by a hollowiber oxygenator with a priming solution containing saline, HES and heparin. Five animals without EC served as a control. The coagulation system was characterized by thromboelastography (TEG), thrombin generation, coagulation factor levels, platelet numbers and function (aggregation). A GoreTex patch was inserted into the carotid artery, bleeding occurred from the stitch channels. The efects of intravenous substitution therapy by PCC (Beriplex P/N, 30 U/kg, n = 6) compared with placebo (n = 6) on bleeding from the stitch channels was investigated. Results EC and hypothermia compromised the coagulation system. Coagulation factor levels were decreased, TEG and thrombin generation became pathologic. Platelet count and aggregation were decreased. Blood loss from the stitch channels of the GoreTex patch was doubled in the EC group when compared with animals without EC. After substitution therapy with PCC, blood loss decreased signiicantly from 83.0 ± 48.4 ml in the EC + placebo to 27.2 ± 35 ml in the EC + PCC group (P <0.025, Wilcoxon test; Figure 1). PCC normalized the impaired coagulation. Introduction Dilutional coagulopathy following massive bleeding is the result of clotting factor dilution and impaired ibrin polymerization after infusion of colloidal plasma expanders. Although ibrinogen has been clinically used to treat dilutional coagulopathy [1,2], the efects of ibrinogen dosages on normalizing coagulation function is unclear. This study investigated the efect of six diferent ibrinogen dosages (range: 37.5 to 600 mg/kg) on ROTEM® parameters and overall blood loss in a pig model for dilutional coagulopathy. Methods Forty-two pigs underwent a 60% hemodilution with Voluven® (HES130/0.4). A standardized bone injury was performed after the completion of hemodilution. Animals were then randomized to receive 37.5, 75, 150, 300, 450 or 600 mg/kg ibrinogen (FGTW, LFB, France) or 500 ml saline. Four hours after ibrinogen administration a standardized liver injury was performed. Animals were then observed for 2 hours or until death. Blood loss was measured and tissue samples were collected at the end of the study. Hemodynamic and coagulation parameters were measured at baseline (BL), after hemodilution, 15 minutes, 1, 2 and 4 hours after drug infusion and 2 hours after liver injury or right before the animal’s death. Statistical signiicance was set at P <0.05. Results Fibrinogen dosages of 150 mg/kg and higher completely reversed dilutional coagulopathy: the maximum clot irmness (MCF) which was decreased after hemodilution (36 ± 3 vs 65 ± 4 mm at BL, P <0.05), returned to BL levels after ibrinogen administration (69 ± 5 mm). Blood loss from bone and liver injury signiicantly decreased with increased ibrinogen dosages: 42 ± 19 (sham), 34 ± 14 (75 mg/kg), 29 ± 13 (150 mg/kg) and 28 ± 10 ml/kg BW (600 mg/kg). No thrombotic events occurred. Conclusions In a swine model of 60% hemodilution with bone and liver injury, ibrinogen administration (150 mg/kg and above) normalized MCF and decreased blood loss. Infusions of 12 times the dosage recommended in humans did not induce hypercoagulability. References 1. 2. Fenger-Eriksen C, et al.: J Thromb Haemost 2009, 75:795-802. Mittermayr M, et al.: Anesth Analg 2007, 105:905-917. P370 Tranexamic acid reduces blood loss in postpartum haemorrhage A Ducloy-Bouthors1, F Broisin2, H Keita3, S Fontaine4, S Depret1, F Legoef5, L Mandelbrot3, R Rudigoz2, B Jude1 1 Centre Hospitalier Regional Universitaire, Lille, France; 2Hôpital Croix Rousse HCL, Lyon, France; 3Hôpital Louis Mourrier APHP, Colombes, France; 4Maternité Monaco CH, Valenciennes, France; 5Maternité Paul Gellée, Roubaix, France Critical Care 2010, 14(Suppl 1):P370 (doi: 10.1186/cc8602) Figure 1 (abstract P368). Blood loss from a GoreTex Patch after EC. Conclusions Hypothermia and EC led to a compromised coagulation system, resulting in increased hemorrhage. The deicit in coagulation could be overcome by substitution therapy with PCC. Elevated blood loss from stitch channels was decreased signiicantly after treatment with PCC. It was concluded that PCC should be beneicial in patients undergoing cardiovascular surgery with an EC-induced coagulopathy. Introduction Postpartum haemorrhage (PPH) is a leading cause of maternal death. Present guidelines for PPH management focus on uterotonic treatments, while the potential eicacy of antiibrinolytic drugs has been poorly explored in this indication. Methods After approval by the ethics committee, we randomly assigned women with PPH >800 ml after vaginal delivery to receive intravenous tranexamic acid (TXA) (4 g within 1 hour, followed by 1 g/hour during 6 hours) (TXA group) or no antiibrinolytic treatment (Control group). Monitoring and management were performed according to the guidelines. Additional procoagulant treatments (coagulant concentrates, fresh frozen plasma, platelets) were used only when PPH became intractable (>2,500 ml or >500 ml/30 minutes). Embolization or surgery was performed when considered clinically necessary. Blood loss, maternal morbidity and safety were collected at four time points: inclusion (T1), T1 + 30 minutes (T2), T1 + 2 hours (T3), and T1 + 6 hours (T4). The study plan, based on the hypothesis that TXA would induce a 20% blood loss reduction with an α risk of 5% and a β risk of 10%, required the inclusion of 72 patients in each group. Statistical analysis used the SAS system. Results One hundred and forty-four patients were included, 72 in the TXA group and 72 in the control group. Management data were similar between the two groups. In the TXA group, as compared with the control Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 group: blood loss was 46% lower between T2 and T3 (P = 0.026), and 49% lower between T2 and T4 (P = 0.0012); bleeding duration was shorter (31 ± 28 vs 65 ± 95 minutes, P = 0.004); and maternal morbidity was reduced (hemoglobin drop >4 g/dl: n = 15 vs 34, P <0.001; blood transfusion requirement: n = 14 vs 20, P = NS; overall number of transfused packed red blood cells: n = 42 vs 62, P <0.001; number of severe PPH (Charbit criteria 1): n = 23 vs 36, P = 0.028). Invasive procedures were needed in four women in the TXA group and in seven women in the control group (P = NS). Transient visual and digestive side efects were observed more frequently in the TXA group than in the control group (17 vs 4 P = 0.028). Conclusions These results show, for the irst time, that TXA, when administered early in the management of PPH, reduces blood loss and maternal morbidity, with only minor and transient side efects. As TXA is a readily available and cheap hemostatic agent, we strongly suggest that it should be further investigated as an adjuvant treatment in PPH. Reference 1. J Thromb Haemost 2007, 5:266-273. P371 Regional variation of the of-licence use of rFVIIa for patients with uncontrolled haemorrhage in England MH Spivey, RL Eve, MR Dufy Derriford Hospital, Plymouth, UK Critical Care 2010, 14(Suppl 1):P371 (doi: 10.1186/cc8603) Introduction In 1999 the irst publication appeared of the use of recombinant factor VIIa (rFVIIa) for uncontrolled haemorrhage [1]. Since then there has been widespread international use of rFVIIa in this setting. Consensus guidelines have been published [2], but there is much variation in its administration [3]. Methods Review of the blood bank databases of all six acute hospitals in the southwest of England between January 2000 and February 2009 was undertaken to reveal all prescriptions of rFVIIa. Case notes were analysed and the administration of all blood products for 24 hours either side of rFVIIa administration was extracted from the blood bank databases. Results Eighty-two patients were identiied who had received of-licence rFVIIa. Of these, full data were available on 67 patients. There was unequal use between hospitals; Plymouth had 33% of use compared with Taunton, with only 4%. A total 65.7% of patients were male and the mean age was 56.6 years. The mean APACHE II score was 18.4 (± 7.4) and 40.3% patients died in ≤96 hours. The mean dosage administered was 80.9 μg/kg (± 21.3). The number of annual prescriptions shows a bimodal pattern with peaks in 2005 and 2008. The distribution of usage was predominantly with general and vascular surgical patients (39%), but trauma (14.9%), obstetrics (13.4%) and cardiac surgery (13.4%) were the next most frequent specialties. rFVIIa was given after a mean of 17.6 (± 11.2) units of packed red cells, 8.8 (± 5.9) units of fresh frozen plasma and 2.3 (± 1.9) pooled platelets. Following rFVIIa transfusion of all blood products was markedly less, and only three patients received a repeat dose of rFVIIa. The prothrombin time decreased from a mean of 18.9 seconds to 13.9 seconds following rFVIIa. Thirty-six per cent of patients had <50 platelets at administration and 40% were acidotic with pH <7.2. Sixty-eight per cent patients had a haematocrit <0.25 and 30% of patients were hypothermic. Conclusions Of-label prescribing of rFVIIa varies widely across the southwest region. Its use as an adjunctive therapy for uncontrolled haemorrhage has often been unsuccessful. Our analysis of prescribing rFVIIa in this setting relects the practice of the larger Australian series in terms of indications and dosage; however, the mortality at 28 days of 32% is lower than in our series [3]. There is still heterogeneity in prescribing rFVIIa and its use does not conform to European guidelines [2]. References 1. 2. 3. Kenet G, et al.: Lancet 1999, 354:1879. Vincent JL, et al.: Crit Care 2006, 10:R120. Willis CD, et al.: Int Med J 2009. [Epub ahead of print. PMID: 19712199] S125 P372 Early use of factor VIIa in cardiac surgery is associated with lower rates of blood transfusions without impact on outcome F Galas, L Hajjar, F Zampieri, A Roquim, R Kalil, V Guimaraes, J Auler Jr Heart Institute, São Paulo, Brazil Critical Care 2010, 14(Suppl 1):P372 (doi: 10.1186/cc8604) Introduction Bleeding after cardiac surgery is a common state, associated with adverse efects. Factor VIIa is a recombinant factor able to restore blood coagulation without signiicant adverse efects. We aimed to evaluate whether the early use of factor VIIa reduces bleeding and the rates of transfusion. Methods We studied 241 patients submitted to cardiac surgery who presented bleeding after heparin reversal and a irst replacement of clotting factors. From these, 81 patients were submitted to valve procedures, 51 coronary artery bypass surgery (CABG), 60 valve + CABG, 35 aortic ascending surgery and 14 cardiac transplant. From these, 131 received factor VIIa early (in the intraoperative room) and 110 received the drug in the ICU. Results Both groups of patients presented a statistically signiicant reduction of blood transfusion after receiving factor VIIa (P <0.001). The group of patients undergoing early use presented a lower rate of reoperations due to bleeding (P <0.01), and received less units of red blood cells (P <0.01), fresh frozen plasma (P <0.01), cryoprecipitate and platelets (P <0.01). Also, we detected a low incidence of infection in the group who received the factor in intraoperative room. Conclusions Early use of factor VIIa in patients who bleed after cardiac surgery is associated with lower rates of reoperations, lower rates of transfusion and lower incidence of infection. This suggests the drug should not be used as a last therapeutic tool and may be indicated earlier in the management of bleeding. Reference 1. Napolitano LM, et al.: Red blood cell transfusion in adult trauma and critical care. Crit Care Med 2009, 37:3124-3157. P373 Low-frequency hemoviscoelastography in monitoring coagulation disorders after abdominal surgery for cancer O Tarabrin1, V Grubnik1, P Pustovoyt2, O Osipenko2, S Shcherbakov1, D Gavrichenko2 1 Odessa Medical University, Odessa, Ukraine; 2Regional Clinical Hospital, Odessa, Ukraine Critical Care 2010, 14(Suppl 1):P373 (doi: 10.1186/cc8605) Introduction Venous thromboembolism is of the most common complications in cancer patients and may be due to the hypercoagulable state of malignancy and to its surgical treatment. Methods Patients undergoing planned curative open surgery for abdominal cancer received MEDNORD (Ukraine Co. analyzer) analysis (HVG), a viscoelastic test that measures clot formation and includes information on the cellular as well as the plasmatic coagulation system. We examined the eicacy of a variety of coagulation tests. A complete coagulation screen, activated clotting time, thromboelastography (TEG) and haemoviscoelastography (HVG) were performed before surgery, at the end of surgery, and on postoperative days 1, 2, 3, and 7; they were analyzed for the reaction time and the maximal amplitude (MA). Results We calculated the elastic shear modulus of standard MA (Gt) and HVG MA (GH), which relect the total clot strength and procoagulatory protein component, respectively. The diference was an estimate of the platelet component (Gp). There was a 14% perioperative increase of standard MA, corresponding to a 48% increase of Gt (P <0.05) and an 80 to 86% contribution of the calculated Gp to Gt. We conclude that serial standard thromboelastography and the HVG viscoelastic test may reveal the independent contribution of platelets and procoagulatory proteins to clot strength. Using multiple linear regressions, all coagulation, TEG and HVG variables were used to model postoperative hypercoagulation. However, three components of the routine coagulation assay, including bleeding time, prothrombin time and platelet count, could be modeled to show prolonged postoperative hypercoagulability (P <0.01). We conclude that all components of the HVG test relect postoperative coagulopathies; these results suggest that it may be useful in determining the coagulation status of cancer patients perioperatively. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S126 Conclusions Postoperative hypercoagulability, occurring for at least 1 week after major cancer abdominal surgery, may be demonstrated by the HVG viscoelastotest. This hypercoagulability is not relected completely by standard coagulation monitoring and the TEG HVG viscoelastotest provides a fast and easy-to-perform bedside test to quantify in vitro hemocoagulation. P375 Efect of transfusion, leukocyte-depleted blood product on onset of new septic shock and mortality in septic shock H Hayami, S Nagai, A Sakurai, K Okamura, J Yamada, H Kawakami, K Fujimoto, O Yamaguchi, Y Koide Yokohama City University Medical Center, Yokohama, Japan Critical Care 2010, 14(Suppl 1):P375 (doi: 10.1186/cc8607) P374 Reliability of the HemoCue® hemoglobinometer in critically ill patients D Frasca, C Dahyot-Fizelier, A Medard, L Laksiri, F Petitpas, O Mimoz University Hospital, Poitiers, France Critical Care 2010, 14(Suppl 1):P374 (doi: 10.1186/cc8606) Introduction A number of studies have observed decreased survival associated with transfusion. Leukocyte-mediated immunosuppression may contribute to postoperative infectious complications. There is evidence for a beneit with the use of leukocyte reduced transfusion, but it is unclear among septic shock patients. In Japan, leukocyte-depleted blood products have been used since 2007. We assessed the efect of transfusion and the eicacy of the use of leukocyte-depleted blood products for new onset of septic shock and mortality among patients with septic shock. Methods A total of 101 septic shock patients at a single university general ICU were enrolled in the study. A target hemoglobin (Hb) concentration of 10 g/dl (Ht 30%) was considered for allogeneic red cell transfusion (to maintain central venous saturation >70%) during the early phase of severe sepsis, and Hb was kept in the range of 7 to 9 g/dl in the stable phase except for the patients with particular disease (acute coronary syndrome, and so forth). Fresh frozen plasma was used to keep PT-INR <1.67, and platelet transfusion was done due to the patient’s condition (for example, postoperative, and so forth). Results Eighty-six patients (85%) received transfusion (group T: age 68 ± 12, APACHE II 25.9 ± 9.5) and 15 received no blood product (group NT: age 63 ± 14, APACHE II 27.4 ± 3.2). Frequent sites of infection were the lung (46%), peritoneum (17%), mediastinum (12%), and gastrointestinal tract (7%) (NS between groups). Overall mortality for group T vs group NT was 27/86 (31%) vs 3/15 (20%) (P = 0.54). Onset of new septic shock for group T vs group NT was 27/86 (31%) vs 4/15 (27%) (P = 0.71). Survivors received 26.6 ± 31.2 Japanese units of total blood product and 44.6 ± 35.6 units for patients who died, respectively (1 American unit is almost equivalent to 2 Japanese units) (P = 0.013). For group T, 56 patients received leukocytereduced blood product (LRB) and 29 received ordinary product (Cont.). Overall mortality for LRB vs Cont. was 40/56 (71%) vs 18/29 (62%) (P = 0.38). Conclusions The total amount of blood products received was highly associated with increased mortality, but there was no obvious adverse efect of transfusion to the onset of new septic shock. No association between overall mortality and the use of leukocyte depleted blood was identiied in patients with septic shock. Introduction In the ICU, the hemoglobin concentration is currently estimated by portable hemoglobinometer and in emergency transfusion a decision can be based on that result. The aim of the study was to compare the HemoCue® with laboratory determination of the blood hemoglobin concentration in critically ill patients with a high risk of bleeding. Methods A prospective observational study was conducted in three adult surgical ICUs of a university hospital. After ethic committee approval, 198 consecutive patients requiring 1,166 determinations of hemoglobin concentration were included. Hemoglobin was measured from an arterial blood sample at the laboratory (Hbm) and estimated at the bedside (Hbe,a) using the same blood sampling and a portable hemoglobinometer (HemoCue® Hb201+). Simultaneously, a capillary measurement (Hbe,cap) was performed at the bedside using the same device. Results The mean diference (bias, Figure 1) between Hbe,cap and Hbm was –0.2 g/dl (95% CI, –0.3 to –0.1) and limits of agreement –1.3 g/dl (95% CI, –1.4 to –1.2) to 1.7 g/dl (95% CI, 1.6 to 1.9). Discrepancies between Hbe,cap and Hbm were greater than 1 g/dl in 30.8% of cases. The accuracy of HemoCue® was not afected by the unit of hospitalization, the patients’ severity assessed by SAPS II score on admission, the site of lancet puncture (inger or ear), the administration of norepinephrine, the presence of hypothermia (body temperature <36.3°C) or by a hemoglobin level below 10 g/dl or 8 g/dl. The bias between Hbe,a and Hbm was –0.1 g/dl (95% CI, –0.2 to 0.2) and limits of agreement –1.1 g/dl (95% CI, –1.2 to –1.0) and 1.0 g/dl (95% CI, 0.9 to 1.1). Conclusions Capillary HemoCue® is not accurate enough to base therapeutic decisions such as blood transfusion on. The performance of the method is improved with the use of arterial blood. P376 Transfusion Requirements After Cardiac Surgery (TRACS) study: preliminary data of a randomized controlled clinical trial L Hajjar1, F Galas1, M Sundin1, R Nakamura1, C Silva1, T Mauad2, P Pomerantzef1, P Bueno1, R Kalil Filho1, JL Vincent3, J Auler Jr1 1 Heart Institute, São Paulo, Brazil; 2São Paulo University, São Paulo, Brazil; 3 Erasme Hospital, Brussels, Belgium Critical Care 2010, 14(Suppl 1):P376 (doi: 10.1186/cc8608) Figure 1 (abstract P374). Introduction There are no prospective studies comparing outcomes between restrictive or liberal strategies in cardiac surgery. This study is a double-blind randomized study to determine whether a restrictive strategy of red cell transfusion and a liberal strategy produced equivalent results in patients submitted to cardiac surgery. Methods Until November 2009 we enrolled 380 patients undergoing elective cardiac surgery and randomly assigned 185 patients to a restrictive strategy of transfusion, in which red cells were transfused if the hematocrit concentration dropped below 24%, and 195 patients to a liberal strategy, in which transfusions were given when the hematocrit fell below 30%. Both transfusion strategies were followed into the operative room and during the ICU stay. We compared the rates of complications and death from all causes during the hospital stay and clinical outcomes of patients after 90 days. Adult patients, after written informed consent, were allocated if they would be submitted to elective primary surgery or were redone adult cardiac surgical patients for coronary artery bypass grafting, valve procedure or combined procedures. Results Overall, hospital mortality was similar in the two groups (4.7% vs 5.3%, P = 0.11). The rates of complications were similar in the two groups Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 (28.3% in the restrictive-strategy group and 26.1% in the liberal-strategy group, P = 0.33). The ICU stay was signiicantly lower in the restrictivestrategy group (2.2 days vs 4.1 days, P = 0.05). There was no diference in 90-day mortality between groups. Conclusions A restrictive strategy of red cell transfusion is at least as efective as and possibly superior to a liberal transfusion strategy in patients submitted to cardiac surgery. References 1. 2. Napolitano LM, et al.: Clinical practice guideline: red blood cell transfusion in adult trauma and critical care. Crit Care Med 2009, 37:3124-3157. Hébert PC, et al.: Controversies in RBC transfusion in the critically ill. Chest 2007, 131:1583-1590. P377 Analysis of red cell transfusion practices in patients without active haemorrhage over a 12-month period in a UK intensive care unit RL Eve, MH Spivey, S Hart, MR Dufy Derriford Hospital, Plymouth, UK Critical Care 2010, 14(Suppl 1):P377 (doi: 10.1186/cc8609) Introduction The deleterious efects of red blood cell (RBC) transfusion are well known [1] and restrictive transfusion practices are safe in patients without active haemorrhage [2]. Our objective was to determine transfusion practices in critically ill patients without evidence of ongoing bleeding to establish our conformity with published guidelines [3]. Methods All adult ICU patients receiving RBC transfusions between 1 September 2008 and 31 August 2009 were included in the analysis. Data were collected on demographics, APACHE II score, ICU and hospital length of stay (LOS), ICU and hospital mortality, presence of ischaemic heart disease (IHD), and pre/post-transfusion haemoglobin concentrations in g/dl ([Hb]). Subgroup analyses were performed for patients with IHD, age <55 years or APACHE II ≤20. We analysed patients with IHD because beneit from liberal transfusion has not been conirmed [1] whereas the latter two subgroups have shown a mortality beneit with restrictive transfusion [2]. Results A total of 1,723 patients were admitted to the ICU during the study period. Two hundred and ive patients (11.9%) received RBCs, of whom 47 had active bleeding and were excluded from further analysis. The remaining 158 patients (9.2%) received a total of 477 units RBCs (median 2.0 units/patient, IQR 1.0 to 3.8). Median pre-transfusion [Hb] was 7.7 (IQR 7.3 to 8.2) with a post-transfusion [Hb] of 9.2(IQR 8.5 to 9.8). Median ICU and hospital LOS in days was 10.9 (IQR 4.9 to 18.8) and 26.9 (IQR 14.0 to 45.0). ICU and hospital mortalities were 34.2% and 44.9%, respectively. Patients with acute IHD had a pre-transfusion [Hb] of 8.3(IQR 7.8 to 8.8) with a posttransfusion [Hb] of 9.4 (IQR 9.2 to 10.2) whilst patients with chronic IHD had values of 7.9 (IQR 7.4 to 8.4) and 9.4 (IQR 8.5 to 9.8), respectively. In patients aged <55 years, pre/post-transfusion values were 7.5 (IQR 7.1 to 8.0) and 9.2 (IQR 8.5 to 10.0), respectively, and patients with APACHE II ≤20 had values of 7.7 (IQR 7.3 to 8.2) and 9.2 (IQR 8.5 to 9.8), respectively. Conclusions [Hb] transfusion triggers were >7 in all subgroups and post-transfusion [Hb] was >9. Transfusion strategies were too liberal. It is important to restrict transfusions to limit morbidity and mortality and to make eicient use of RBCs [4]. This study demonstrates the importance of regular audit and will be used to inform local guidelines. References 1. 2. 3. 4. Marik PE, et al.: Crit Care Med 2008, 36:2667-2674. Hebert PC, et al.: N Engl J Med 1999, 340:409-417. Thomas D, et al.: Red Cell Transfusion 2 [http://www.aagbi.org/publications/ guidelines/docs/red_cell_08.pdf ] Joseph BG, et al.: Transfusion 2009, 49:2060-2069. P378 Efects of red blood cell transfusion in central venous saturation and lactate levels in patients with septic shock BF Mazza, M Assunção, F Freitas, M Jackiu, FR Machado Universidade Federal de São Paulo, Brazil Critical Care 2010, 14(Suppl 1):P378 (doi: 10.1186/cc8610) Introduction Transfusion of red blood cells has been used with the objective of improving oxygen delivery to the tissues in the critically ill patient. However, the appropriate hemoglobin (Hb) level is still S127 controversial in septic shock patients [1,2]. The objective of this study was to evaluate the efect of red blood cell transfusion on the central venous saturation (SvcO2) and lactate levels in patients with septic shock with two diferent levels of Hb. Methods Patients with less than 48 hours of septic shock and Hb levels under 9.0 g/dl were randomized to maintain Hb over 9.0 g/dl (Group 1) or over 7.0g/dl (Group 2). Before and up to 1 hour after each transfusion, Hb, lactate and SvcO2 were determined. Results were expressed as median (25% to 75% percentile) or percentage and analyzed through chi-square or Mann–Whitney test. P <0.05 was considered signiicant. Results Forty-six patients were included with a total of 74 transfusions, being 39 in Group 1 and 35 in Group 2, without any diference in demographic or hemodynamic data between the groups. Before and after Hb levels were 8.5 (8.2 to 8.7) g/dl and 9.4 (9.1 to 9.5) g/dl in Group 1 (P = 0.000) and 6.8 (6.6 to 6.9) g/dl and 7.6 (7.4 to 7.8) g/dl in Group 2 (P = 0.000). A reduction in median lactate after transfusion was found in Group 2 patients (22.0 (18.1 to 29.1) mg/dl and 20.0 (16.3 to 25.2) mg/dl, P = 0.005) but not in Group 1 (17.2 (16.3 to 23.9) mg/dl and 18.1 (15.4 to 21.8) mg/dl, P = 0.23). The same occurred regarding SvcO2 with improved values only in Group 2 (68.0 (64.0 to 72.0)% and 72.0 (69.0 to 75.0)% in Group 2, P <0.000) and not in Group 1 (72.0 (69.0 to 74.0)% and 72.0 (71.0 to 73.0)%, P = 0.98). In patients with altered lactate levels a reduction was found regardless of the basal levels of hemoglobin (P = 0.002 and P = 0.001 for Groups 1 and 2, respectively). The same was demonstrated in patients with SvcO2 <70% (P = 0.007 and P = 0.000 for Groups 1 and 2, respectively). On the other hand, patients with normal levels of both perfusion parameters did not present a worsening of those variables, either in Group 1 or Group 2. Conclusions Red blood cell transfusion improved tissue perfusion in patients with signs of hypoperfusion regardless of basal levels of Hb. Transfusion did not seem to worsen tissue perfusion in patients without signs of hypoperfusion, even in the group with Hb levels above 9.0 g/dl. References 1. 2. Hebert PC: N Engl J Med 1999, 340:409-417. Rivers E: N Engl J Med 2001, 345:1368-1377. P379 Massive transfusion in paediatric trauma: a single-centre experience R Hearn, M Tecle, S Rajan, N Edmonds The Royal London Hospital, London, UK Critical Care 2010, 14(Suppl 1):P379 (doi: 10.1186/cc8611) Introduction Uncontrolled haemorrhage is a leading cause of early mortality in trauma. Administration of blood products, packed red cells and fresh frozen plasma (PRBC:FFP) in the ratio of 1:1 is associated with improved mortality in major haemorrhage in adult trauma. However, there is little evidence available for the management of major haemorrhage in the context of paediatric trauma. Methods We retrospectively analysed the local paediatric trauma database of all children following trauma call activation on arrival at the emergency department of The Royal London Hospital, a major urban trauma centre in London. The study period was over 15 months, May 2008 to August 2009. During this period, there has been no major haemorrhage policy within the centre for paediatric trauma. We collected data on demographic proile, injury severity scores, blood products transfused in the irst 24 hours and the outcomes. We deined massive transfusion as the requirement of packed red cells >40 ml/kg in the irst 4 hours or >80 ml/kg in the irst 24 hours. Results Two hundred and twenty-seven children presented to the emergency department during this period following major trauma call activation. The median age at presentation was 10.2 years. Thirteen (5.7%) children had major haemorrhage. The median ISS was 35 (IQR 10 to 60). All but one were males. Three had penetrating trauma, one of whom made it to theatre, but all died. Four had emergency damage control surgery. Abnormal results were seen in three patients, each having one abnormal result (INR =1.9 and APTT = 86, low Hb = 7.6, thrombocytopaenia = 63). Eight of the 13 patients received additional blood products such as fresh frozen plasma, platelets and cryoprecipitate. However, no patient received the ratio of blood products of PRBC:FFP of 1:1 as practised in adult trauma. Two patients had no admission bloods done. Worsening coagulation Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 parameters were seen in two patients when measured post transfusion and the remaining 11 patients did not have routine monitoring of blood parameters post transfusion. Eight (62%) patients died, of which seven died in the emergency department. Conclusions Major haemorrhage is associated with a very high mortality in severely injured children. We recommend rigorous monitoring of laboratory parameters to guide appropriate administration of blood products. There is a need for instituting a major haemorrhage policy in paediatric trauma and consideration of point-of-care testing of blood parameters. P380 Cytokine levels evaluation during acute isovolemic anemia M Kahvegian1, DT Fantoni2, DA Otsuki1, CA Holms1, CO Massoco3, JO Auler Jr1 1 Faculdade de Medicina da Universidade de São Paulo, Brazil; 2School of Veterinary Medicine, Universidade de São Paulo, Brazil; 3Sales Gomes Consulting, São Paulo, Brazil Critical Care 2010, 14(Suppl 1):P380 (doi: 10.1186/cc8612) Introduction To date there is poor evidence that documents the beneit of red blood cell transfusion on clinical outcome. Acceptance of a lower transfusion trigger in the perioperative period requires detailed information regarding the efects of volume replacement in diferent organs and systems. Since luids can have a widely divergent impact on the immune response, this study was undertaken to determine the cytokine levels in a model of acute isovolemic anemia (AIA) with hydroxyethyl starch (HES) and gelatin (GEL). Methods Twenty-one pigs were anesthetized, instrumented and randomized into three groups: Control, HES and GEL. Animals in the HES and GEL groups were submitted to acute isovolemic anemia to a target hematocrit of 15% with volume replacement performed with HES 130/0.4 and GEL at a 1:1 ratio. The withdrawn blood was returned to the animals 120 minutes after the end of AIA. TNF, IL-1, IL-6 and IL-10 measurements were performed with blood samples collected at the femoral vein at the following time points: Baseline, after instrumentation (INST), immediately after AIA (AIA), 60 minutes after AIA (60AIA), 120 minutes after AIA (120AIA), 60 minutes after blood infusion (60BI) and 120 minutes after blood infusion (120BI). The cytokines were measured in serum by a commercially available ELISA with speciic monoclonal antibodies. Two-way analyses of variance (ANOVA) and a Tukey test were used to assess its signiicance (P <0.05). Results TNF varied signiicantly among the groups in diferent time points (AIA: Control, 91 ± 16 and GEL, 221 ± 61; P <0.05; 60AIA: Control, 76 ± 15; HES, 172 ± 42; P <0.05 and GEL, 323 ± 77; P <0.001; 120AIA: Control, 98 ± 6 and GEL, 304 ± 66; P <0.01; 120BI: Control, 71 ± 7 and GEL, 211 ± 71; P <0.05). In relation to IL-1, only in the GEL group (224 ± 56) was veriied a statistical signiicant at time point 60AIA when compared with Control (84 ± 17; P <0.05). When IL-6 levels were studied, GEL presented S128 a statistically signiicant at 60AIA (GEL, 331 ± 65) when compared with Control (146 ± 19; P <0.05). Serum IL-10 levels in GEL-treated animals were statistically signiicantly elevated at 60AIA (Control, 17 ± 3 and GEL, 46 ± 12; P <0.01) and 120BI (Control, 21 ± 5 and GEL, 59 ± 11; P <0.05). Conclusions Fluid replacement inluences the cytokine measurements during acute isovolemic anemia expressed by serum TNF, IL-1, IL-6 and IL-10 increases, especially in GEL group. P381 Haemodynamic alterations in community-acquired sepsis at early stage S Hettwer, J Wilhelm, M Schürmann, H Ebelt, K Werdan Martin-Luther-University, Halle (Saale), Germany Critical Care 2010, 14(Suppl 1):P381 (doi: 10.1186/cc8613) Introduction Community-acquired sepsis at an early stage is common, but haemodynamic alterations remain unclear. The aim of the study was to characterize cardiovascular alterations in patients of our ProFS (monocentric observational) study, which was to characterize patients with sepsis in the emergency department. Methods Systemic vascular resistance (SVR) and cardiac output (CO) were measured non-invasively using a TaskForce monitor (CNSystems, Graz, Austria) after admission, 24 hours and 72 hours. Indexed values were calculated (SVRI (dyn·second/cm5/m2), CI (l/minute/m2)). Procalcitonin (PCT, ng/ml) was measured in serum. Results A sample of 64 patients of 208 included patients received haemodynamic examination. Mean age was 61.8 ± 18.0 years, 62.7% were male. Patients were divided by PCT <2 and ≥2. Age, gender and previous medical history were comparable in both groups. The heart rate was 99.8 ± 21.6 vs 104.6 ± 23.0/minute (P = NS) and the mean artery pressure was 89.5 ± 15.6 vs 81.6 ± 21.5 mmHg (P <0.01). Mean SVRI in patients with PCT <2 was 2,934 ± 1,045 vs 2,376 ± 842, P <0.05 at the time of admission. No diference was found after 24 hours (2,959 ± 1,002 vs 2,924 ± 1,324, P = NS) and 72 hours (3,123 ± 931 vs 3,556 ± 1,524, P = NS). On the contrary, for patients with PCT ≥2 the increase after 72 hours was signiicant (P <0.05). Diferences after admission could not be observed for CI between patients with PCT <2 vs ≥2. Mean values after admission were 2.7 ± 1.0 vs 2.8 ± 0.8, after 24 hours 2.5 ± 0.8 vs 2.5 ± 0.5, and after 72 hours 2.3 ± 0.7 vs 2.3 ± 0.6 (all: P = NS). See Figure 1 Conclusions Patients with community-acquired sepsis in the emergency department had an elevated SVRI. At the time of admission patients with high PCT had a signiicantly lower SVRI than patients with low PCT. Cardiac index at the time of admission was at a lower limit of normal range in all patients. These indings are in strong contrast to the classic pattern of sepsis on the ICU, where SVRI is keenly reduced and CI elevated. They implicate that patients with sepsis in the emergency department may beneit more from application of luid and positive inotrope substances than from vasopressor. Figure 1 (abstract P381). Systemic vascular resistance index and cardiac index in sepsis in the emergency department. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P382 Epidemiology of severe sepsis in India: an update S Todi1, S Chatterjee1, S Sahu2, M Bhattacharyya1 1 AMRI Hospitals, Kolkata, India; 2Kalinga Hospital, Bhubaneswar, India Critical Care 2010, 14(Suppl 1):P382 (doi: 10.1186/cc8614) Introduction A multicentre, prospective, observational study conducted in four intensive therapy units (ITUs) in India from June 2006 to June 2009 to determine the incidence and outcome of severe sepsis among adult patients. Methods All patients admitted to the ITU were screened daily for SIRS, organ dysfunction and severe sepsis as deined by the ACCP and SCCM. Patient with severe sepsis were further studied. Results A total of 5,478 ITU admissions were studied. SIRS with organ dysfunction was found in 1,385 (25%) patients, of which 731 (52.77%) were due to sepsis. The incidence of severe sepsis was 16.45% of all admissions. Mean age of the study population was 58.17 years (SD 18.66), of which 57.71% were male. The median APACHE II score was 13 (IQR 13 to 14) with predominant (90.93%) medical admission. ITU mortality of all admissions was 12.08% and that of severe sepsis was 59.26%. Hospital mortality and 28-day mortality of severe sepsis were 65.2% and 64.6%, respectively. The standardized mortality ratio of severe sepsis patients was 1.45. Median duration of stay in the ITU for the severe sepsis cohort who survived was 13 days (IQR 11 to 17). The number of episodes where infection was the primary reason for admission to the ITU was 86.32%. Culture positivity was found in 61.6%. The lung was the predominant source of sepsis (57.45%). Gram-negative organisms were responsible for 72.45% of cases and Grampositive for 13.13%. The rest were parasitic, viral and fungal infection. Conclusions Severe sepsis was common in Indian ITUs. ITU mortality was higher compared with western literature. Gram-positive infections were less common although incidences of parasitic and viral infection were higher than in the West. P383 Systemic inlammatory response syndrome is reduced by inline iltration in intensive care patients T Jack, M Boehne, BE Brent, A Wessel, M Sasse Medical School Hannover, Germany Critical Care 2010, 14(Suppl 1):P383 (doi: 10.1186/cc8615) Introduction Sepsis, systemic inlammatory response syndrome (SIRS) or organ failure often complicate the clinical course on an ICU. Particulate contamination of the infusion solution may contribute to the clinical deterioration of these patients. Particles have been shown to induce thrombogenesis, deterioration of microcirculation and modulation of immunoresponse. The use of inline iltration with microilters almost completely prevents particulate infusion. We assessed the efect of inline iltration on the reduction of major complications in critically ill children (Clinical Trials.gov ID NCT 00209768). Methods In a randomised, prospective trial 807 paediatric patients admitted to the interdisciplinary PICU of a tertiary university hospital were assigned to either a control or an interventional group, the latter receiving inline iltration (infusion ilter Pall ELD96LLCE/ NOE96E, Braun Intrapur Lipid/Intrapur Neonat Lipid) throughout the whole infusion therapy. Prior to this study, the infusion regimen was optimised to prevent precipitation and incompatibilities of solutions and drugs. Primary objectives included a reduction in the incidence of sepsis, thrombosis, SIRS, organ failure (liver, lung, kidney, circulation) and mortality. Results eight hundred and seven children (343 female, 464 male) with a heterogeneous background of underlying diagnoses and a Gaussian distribution to either the control group (406 patients) or the inline iltration group (401 patients) were included. According to the study criteria, a signiicant reduction in the incidence of SIRS for the interventional group (95% CI, 145 versus 200 patients, P <0.001) was evident. No diferences were demonstrated for the occurrence of sepsis, thrombosis, organ failure (liver, lung, kidney, circulation) or mortality between the control and interventional groups. Conclusions The occurrence of SIRS often complicates the treatment in intensive care medicine. Inline iltration is most efective, reducing the incidence of SIRS, and ofers a novel therapeutic option. S129 P384 Review of central venous catheter-related infections in neurointensive care patients in a tertiary referral centre C Tan, P Nair, A Sule, M Rothburn The Walton Centre for Neurology and Neurosurgery, Liverpool, UK Critical Care 2010, 14(Suppl 1):P384 (doi: 10.1186/cc8616) Introduction Intravenous catheter-related bloodstream infections (ICR-BSI) are a major contributing factor to in-hospital mortality and morbidity, extending the inpatient stay by 10 days and expenditure per patient by £2,000 to £30,000 [1]. A prospective survey was conducted in our unit on all patients with central venous catheters to ascertain the incidence of ICR-BSI, identify the organisms and determine the occurrence of infection from the various sites – femoral, internal jugular and subclavian lines. Methods The survey was carried out over a period of 13 weeks. Data collected from patients’ case notes included site of central line insertion, length of line in situ, reason for line removal and positive blood culture reports. Results During the study period, 104 patients were treated on the unit. Fifty-two central venous lines were inserted in 36 patients (63.5% femoral (n = 33), 32.7% internal jugular (n = 17) and 3.9% subclavian lines (n = 2)). The lines were reviewed daily and removed if indicated clinically (pyrexia or raised white cell count) or if not required. A total 51.5% of femoral lines (n = 17) were removed due to clinical indications, as were 29% (n = 5) of internal jugular and 50% (n = 1) of subclavian lines. The average duration of a line remaining in situ was 4.5 days for femoral, 6 days for internal jugular and 5 days for subclavian lines. Blood cultures were taken at the time of line removal. These yielded positive results in eight femoral, seven internal jugular and one subclavian line. Our survey indicated that the incidence of ICR-BSI in our unit is 30.8% (of this 62.5% coagulase-negative staphylococci (CNS), 12.5% E. coli and Pseudomonas each, and 6.25% MSSA and MRSA each). Conclusions The distribution of microorganisms causing bacteraemia is broadly similar in our unit to that in other teaching hospitals in the UK [2], in that CNS was the commonest organism isolated. However, E. coli and Pseudomonas were the next common organisms, unlike other units where Staphylococcus aureus was the second most prevalent organism. The incidence of bacteraemia from femoral lines (53.7/1,000 catheter-days) was lower than that from internal jugular lines (68.6/1,000 catheter-days) possibly due to a higher index of suspicion in the case of femoral lines and earlier removal (Figure 1). Our study highlights the fact that femoral lines, which are often the safest option for unstable patients with head injury, can be efectively managed with strict adherence to guidelines to reduce ICR-BSI. References 1. 2. Maki DG, Kluger DM, Crnich CJ: The risk of bloodstream infection in adults with diferent intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc 2006, 81:1159-1171. Coello R, Charlett A, Ward V, et al.: Device-related sources of bacteraemia in English hospitals – opportunities for the prevention of hospital-acquired bacteraemia. J Hosp Infect 2003, 53:46-57. Figure 1 (abstract P384). Incidence of ICR-BSI in The Walton Centre for Neurology and Neurosurgery intensive therapy unit. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P385 Clinical impact of diagnosis methods for catheter-related bloodstream infection in ICU patients RO Deliberato, AR Marra, OF Dos Santos, SB Wey Hospital Israelita Albert Einstein, São Paulo, Brazil Critical Care 2010, 14(Suppl 1):P385 (doi: 10.1186/cc8617) Introduction The central venous catheter (CVC) is indispensable in the ICU. Catheter-related bloodstream infection (CR-BSI) is the leading cause of healthcare-associated infections and one of the most important complications from the CVC. Nowadays there are two well-known ways to diagnose CR-BSI: the standard method (withdrawal of the catheter) and the conservative method (without withdrawal of the catheter). Our objective was to compare the in-hospital mortality between the two methods in patients with CR-BSI (short-term catheter) in the ICU. Methods This study was conducted in a 38-bed mixed ICU in a tertiary hospital. We reviewed all episodes of CR-BSI that occurred in our ICU from January 2000 to December 2008. The standard method was deined in a patient with a CVC with at least one positive blood culture obtained from a peripheral vein and a positive semiquantitative (>15 CFU) catheter segment culture whereby the same organism (species and antibiogram) was isolated from the catheter segment and peripheral blood. The conservative method was deined in a patient with a CVC with at least one positive blood culture obtained from a peripheral vein and one of the following: diferential time period of CVC culture versus peripheral culture positivity of more than 2 hours, or simultaneous quantitative blood culture with a ratio ≥5:1 (CVC versus peripheral). Results During the study period, 247 episodes of bloodstream infection were identiied; of these, 192 were catheter-associated bloodstream infection and 55 were CR-BSI (39 standard method and 17 conservative method). Considering the CR-BSI patients, the mean age ± standard variation (SD) was 64 ± 19.29 (years), 75% were under mechanical ventilation, 55% were under vasopressors, 40% were under total parental nutrition, 40% were under hemodialysis, 72% were double lumen and the mean time ± SD in place was 16.32 ± 8.56 (days). The in-hospital mortality of the standard method versus the conservative method did not show any diference (57% vs 75%, P = 0.208). Conclusions This study showed that there is no diference in the inhospital mortality between the standard method versus the conservative method in patients in the ICU with CR-BSI. References 1. 2. O’ Grady NP, et al.: Centers for Disease Control and Prevention. MMWR Recomm Rep 2002, 51:1-29. Bouza et al.: Clin Infect Dis 2007, 44:820-826. P386 Catheter-related bacteremia in a jugular site with tracheostomy and in a femoral site L Lorente, S Palmero, C Naranjo, J Jiménez, J Iribarren, C García, R Galván, J Castedo, J Martínez, M Mora Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain Critical Care 2010, 14(Suppl 1):P386 (doi: 10.1186/cc8618) Introduction In previous guidelines of the Centers for Disease Control and Prevention (CDC) [1] and in the recently published Guidelines of the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America (SHEA/IDSA) [2] it is recommended to avoid the femoral access to reduce the risk of catheter-related bacteremia (CRB). However, in these guidelines there are no recommendations for the catheter site regarding the presence of tracheostomy, and we have not found data about the incidence of CRB comparing a central jugular site with tracheostomy and a femoral site. The objective of this study was to determine whether a jugular site with tracheostomy may have a higher risk of CRB than a femoral site. Methods A prospective, observational, 4-year study (from 1 May 2000 to 30 April 2004) was carried out in the medical–surgical ICU of the University Hospital of the Canary Islands (Tenerife, Spain). We included all patients undergoing a central jugular catheterization with tracheostomy or femoral venous catheterization. Results In the period of study, were used 208 catheters in femoral access and 52 catheters in central internal jugular access with tracheostomy. There S130 were no signiicant diferences between patients with central jugular with tracheostomy and femoral access in age, sex, APACHE II score, diagnosis group, use of mechanical ventilation, use of antimicrobials, use of total parenteral nutrition, use of pulmonary artery catheter, and duration of the catheter. We diagnosed 16 CRB in 208 femoral catheters during 1,679 days of catheterization and 10 CRB in 52 central internal jugular catheters with tracheostomy during 462 days of catheterization. The incidence of CRB was higher in the central internal jugular with tracheostomy than in the femoral site (21.64 vs 9.52 per 1,000 catheter-days; risk ratio = 2.27; 95% conidence interval = 1.04 to 4.97; P = 0.04). Conclusions The femoral site could be considered a more safe venous access than the central internal jugular in patients with tracheostomy to minimize the risk of CRB. References 1. 2. MMWR 2002, 1:1-29. Infect Control Hosp Epidemiol 2008, 29(Suppl 1):S22-S30. P387 A comparative study between conventional and antiseptic impregnated central venous catheters in neurocritical patients S Kifer Macedo, G Castro Lima, L Bonani de Almeida Brito, A Davila Carvalho, JL Fernandes Molina Filho Hospital São José do Avaí, Itaperuna, Brazil Critical Care 2010, 14(Suppl 1):P387 (doi: 10.1186/cc8619) Introduction The central venous catheter (CVC) is very useful in the ICU. A comparative study between antiseptic impregnated and standard catheters is therefore of great value. Methods Alternating the type of CVC used in each patient, we recorded for each patient: sex, age, APACHE II score, GCS, site of the puncture, reason for withdrawal of the catheter and the type of catheter used. The tip of the catheter was cultured. The groups were divided: group I (41 patients, 54 punctures) used the standard CVC, and group II (38 patients, 54 punctures) used the impregnated CVC. Results Sixty-two patients were included (48.38% male). We studied 108 periods, of which 54 were standard CVCs and 54 were impregnated CVCs. The average length of stay was higher for impregnated CVCs (14.11 days) compared with standard CVCs (10.7 days). Excluding death in both groups, the length of stay of the catheter in group I was 10.86 days, compared with 15.43 days in group II. Adding all periods of catheterization, group I have an amount of 578 days, and 762 days for group II. The total duration for group II was 31.84% higher than for group I. Regarding the reason for withdrawal of the CVC, predominant were suspected infection 77.8% of the time for standard CVCs, and 49.1% of the time for impregnated CVCs. The culture of the catheter’s tip was positive in 10 (18.5%) standard CVs, against eight (15.1%) CVCs in the impregnated group. Most patients had GCS <9.The average APACHE II score was17.97 in group I, compared with 19.63 in group II. The predominant site of puncture was the subclavian vein (56.48%). See Figure 1. Conclusions According to our study we observed that the length of stay with use of the impregnated CVC was higher (15.43 days). The rate of colonization was higher in the standard CVC. Patients who require a CVC for long periods have beneited with the use of impregnated CVCs, Figure 1 (abstract P387). Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 because they present long-term use, lower rates of colonization, and avoiding complications related to the procedure of successive punctures and related to the permanence of the catheters. The beneit reached by the use of antiseptic impregnated catheters compensated for the initial expensive cost of 40%. S131 closure therapy had a higher ICU stay and time of mechanical ventilation but lower hospital mortality. Conclusions Vacuum-assisted closure therapy is superior to primary abdominal wall closure in patients with tertiary peritonitis. References 1. 2. P388 Comparison between peripherally inserted central venous catheters and short-term central venous catheter in patients discharged from the ICU S Batacchi1, G Zagli1, S diValvasone2, M Ciapetti1, G Cianchi1, V Tucci1, G Martini1, M Mostardini1, S Proietti1, A Peris1 1 Careggi Teaching Hospital, Florence, Italy; 2Postgraduate School of Anesthesia and Intensive Care, University of Florence, Italy Critical Care 2010, 14(Suppl 1):P388 (doi: 10.1186/cc8620) Introduction The use of peripherally inserted central catheters (PICCs) in the hospital setting has been indicated as an alternative to the shortterm central venous catheter (ST-CVC) in providing prolonged intravenous access. The aim of our study was to assess the rate of complications (deep venous thrombosis (DVT), infections) in patients discharged from the ICU with a PICC or a ST-CVC. Methods A total of 239 patients discharged from our ICU (Careggi Teaching Hospital, Florence, Italy) have been followed (March 2007 to December 2008). PICCs were used in 114 patients (PICC group), whereas ST-CVCs were placed in 125 patients (ST-CVC group). Data, expressed as the mean, were analysed with the Mann–Whitney test and Fisher’s exact test (P <0.05). Results The PICC group and ST-CVC group resulted similar in age (54.3 vs 58.8), BMI (25.6 vs 26.5), SAPS II (46.2 vs 46.5), and ICU length of stay (17.6 vs 16.4). Admission diagnoses in the PICC and ST-CVC groups were also similar: major trauma (38.6% vs 44.8%), sepsis (37.7% vs 32%), postsurgical complications (23.7% vs 23.2%). Total PICC catheter-days were 4,024, whereas total ST-CVC catheter-days were 2,764. Despite similar demographic and clinical characteristics, the PICC group showed a signiicantly higher rate of DVT than ST-CVC group (37.7% vs 14.4%; P <0.01). This diference resulted signiicant also with catheter-day correction (number of events*1,000/catheter-days). The highest incidence of DTV events occurred after 15 days from placement in both groups. Conclusions In our experience, the signiicant rate of DVT found using PICCs induces one to consider a presumably higher thrombogenicity of this kind of catheter. Based on our result, the use of ST-CVC in patients discharged from the ICU, who are at higher risk of DVT development in regard of the recent critically ill status, might be more appropriate. P389 Vacuum-assisted closure of laparostomy, an eicient strategy for complicated intra-abdominal infection NG Germano, IG Gonçalves, B Moya, R Ribeiro Hospital S Bernardo, Setúbal, Portugal Critical Care 2010, 14(Suppl 1):P389 (doi: 10.1186/cc8621) Introduction The chirurgical strategy for infection control in complicated intra-abdominal infections is responsible alone for 40% reduction in mortality. The second look strategy in tertiary peritonitis reduces the mortality and morbidity of the patients. Vacuum-assisted closure therapy can potentially decrease the concentration of proinlammatory cytokines, bacterial count, management of third-space luid and improved input and output monitoring. Methods The authors present a revision of 60 patients with tertiary peritonitis admitted to the ICU after chirurgical infection control. All patients have septic shock at admission. Twelve percent of them were admitted with an open abdomen and vacuum-assisted closure therapy was used. The parameters evaluated were hospital mortality, ICU stay (days) and time of mechanical ventilation (days). Results The patients submitted to vacuum-assisted closure therapy were similar to patients in whom the abdominal wall was closed, regarding the risk factors for peritoneal infection (corticotherapy, oncologic disease, renal insuiciency, hepatic insuiciency, desnutrition, hypoalbuminemia, a high APACHE II score). The patients submitted to vacuum-assisted Becker HP, et al.: Scand J Surg 2007, 96:263-271. Andrabi SIH, et al.: J Ayub Med Coll Abottabad 2007, 19. P390 Comparison between left ventricular tissue Doppler strain imaging and the sequential organ failure assessment score (SOFA score) in patients with severe sepsis or septic shock M Masaki, J Pulido, T Yuasa, S Gillespie, B Afessa, D Brown, S Mankad, J Oh Mayo Clinic, Rochester, MN, USA Critical Care 2010, 14(Suppl 1):P390 (doi: 10.1186/cc8622) Introduction The Sequential Organ Failure Assessment (SOFA) score is a widely used method to describe organ dysfunction/failure in critically ill patients. Although the majority of the studies use the SOFA score in outcome research, little is known about its correlation to left ventricular (LV) function in patients with severe sepsis and septic shock. The purpose of this study was to evaluate the correlation of SOFA score and LV function by tissue Doppler imaging in this patient population. Methods Sixty patients (ages 66 ± 15, men n = 28) admitted to the ICU with severe sepsis or septic shock were prospectively enrolled. Transthoracic echocardiography was performed within 24 hours of admission to the ICU. We measured the LV end diastolic volume index (LVEDVI), LV end systolic volume index (LVESVI), LV ejection fraction (LVEF), mitral deceleration time of E velocity (Dct) and myocardial tissue Doppler strain imaging proiles at the basal, mid and apical portions of the LV septal wall in the LV apical fourchamber view. On the ICU admission day, the SOFA scores were calculated. Signiicantly correlated parameters were subjected to linear regression analysis. P <0.05 was considered signiicant. Results The mean heart rate was 90 ± 17 bpm, mean LV volumes, mean LVEF and mean Dct were within normal limits (LVEDVI; 44.6 ± 15.4 ml/m2, LVESVI; 18.7 ± 11.5 ml/m2, LVEF; 58.9 ± 15.7%, Dct; 175.8 ± 50.2 ms). The mean peak systolic strain measurements were –16.0 ± 5.0% (basal; –18.1 ± 7.0%, mid; –15.7 ± 5.6%, apical; –14.1 ± 6.6%). The mean SOFA score was 10.8 ± 3.9. Linear regression analysis showed correlation between the SOFA score and LVEF (r = –0.40, P = 0.02), Dct (r = –0.34, P = 0.007), mean septal strain (r = 0.40, P = 0.002), mid-septal strain (r = 0.43, P = 0.0007) and apical septal strain (r = 0.36, P = 0.006). Conclusions These results suggest that the higher SOFA score had lower LVEF, lower LV systolic strain and higher LV illing pressure in the patients with severe sepsis or septic shock. An assessment of the left ventricular longitudinal contraction by tissue Doppler strain imaging may serve as a useful tool to evaluate multiple organ failure in this patient population. P391 Systolic and diastolic function and survival in severe sepsis and septic shock: clinical, echocardiographic, biochemical correlation G Landesberg, M Georgieva, Y Meroz, S Goodman, P Levin Hebrew University – Hadassah Medical Center, Jerusalem, Israel Critical Care 2010, 14(Suppl 1):P391 (doi: 10.1186/cc8623) Introduction The exact mechanisms causing cardiac dysfunction in sepsis are still in major part obscure or controversial. Methods All patients who had the criteria for severe sepsis or septic shock underwent daily transthoracic echocardiography examinations from which detailed data on left ventricular end-diastolic, end-systolic volumes areas, and diastolic measurements were obtained. In addition, numerous clinical, hemodynamic, respiratory and laboratory data were prospectively collected, including data on survival up to 2 years after admission. Blood samples were collected, centrifuged and serum separated for additional biomarker tests, mainly troponin and NT-proBNP. Results A total of 262 patients had 712 (2.5 ± 1.4) transthoracic echocardiography examinations. APACHE was 20.6 ± 7.3, 41% had positive blood cultures, >40% died within 4 months. On multivariate Cox survival analysis, the LV ejection fraction, end-diastolic volume and Em wave on tissue Doppler imaging independently predicted improved survival and Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S132 References 1. 2. 3. Dellinger RP, et al.: Crit Care Med 2004, 32:858-73. Parker MM, et al.: Ann Intern Med 1984, 100:483-490. Court O, et al.: Crit Care 2002, 6:500-508. P393 Efects of nitroglycerin on intestinal microcirculatory blood low in patients with abdominal sepsis F Roossien1, EC Boerma1, N Vellinga1, N Bruins1, C Ince2 1 Medical Center Leeuwarden, the Netherlands; 2Academic Medical Center, University of Amsterdam, the Netherlands Critical Care 2010, 14(Suppl 1):P393 (doi: 10.1186/cc8625) Figure 1 (abstract P391). Survival functions. the heart rate independently predicted worse survival (Exp(B) = 0.009, 0.969, 0.9, 1.004 and P <0.0001, P <0.0001, P = 0.001, P = 0.002, respectively). Only 45% of patients with end-diastolic volume index <40 ml survived more than 4 months, compared with 75% survival in patients with enddiastolic volume index >54 ml. Conclusions Decreased ejection fraction, decreased end-diastolic volume, diastolic dysfunction and tachycardia are independent predictors of early mortality in severe sepsis and septic shock. P392 Frequency and clinical spectrum of myocardial dysfunction in severe sepsis and septic shock JN Pulido, T Yuasa, M Masaki, S Gillespie, V Herasevich, S Mankad, B Afessa, D Brown, J Oh Mayo Clinic, Rochester, MN, USA Critical Care 2010, 14(Suppl 1):P392 (doi: 10.1186/cc8624) Introduction Myocardial dysfunction is reportedly a common complication of sepsis that requires speciic management. Although frequently reported in the literature, the clinical spectrum and frequency of this organ failure have not been fully appreciated. We sought to determine the frequency of myocardial dysfunction in severe sepsis and septic shock and to describe the clinical spectrum of this entity with transthoracic echocardiography. Methods Prospective single-center study capturing all patients admitted to the ICU with severe sepsis or septic shock from May 2007 to January 2009. All patients enrolled underwent comprehensive transthoracic echocardiography on admission. The exclusion criteria included <18 years of age, pregnancy, documented ischemic, valvular or congenital heart disease. All patients with LV systolic dysfunction deined as LVEF <50% received a repeat echocardiographic study at 5 days or upon dismissal from ICU. Results One hundred and six patients were enrolled, mean age was 65, and 50% were female. The mean SOFA score was 11. Central venous oxygen saturation was less than 70% in 37% of patients. Twenty-nine patients (27%) had global LV systolic dysfunction (14 = mild, nine = moderate, six = severe), 33 patients (31%) had RV dysfunction (18 = mild, nine = moderate, six = severe), 14 patients had biventricular involvement (13%) and 39 patients (37%) had diastolic illing abnormalities. Of the 29 patients with LV systolic dysfunction on initial examination, 28 received a follow-up echocardiogram and 96% of these patients (n = 27) improved in all parameters. Thirty-day mortality was 39%, 6-month mortality 52%. Myocardial dysfunction did not predict mortality. Conclusions These results conirm that myocardial dysfunction is frequent and broad in patients with severe sepsis and septic shock. Right ventricular involvement and diastolic abnormalities should be considered as part of the clinical spectrum of this entity. There was poor correlation with myocardial dysfunction and mortality and it was reversible regardless of presentation. We should not focus only on left ventricular ejection fraction to diagnose myocardial dysfunction in sepsis, since only a small portion of these patients had isolated LV systolic dysfunction. Introduction In sepsis, microcirculatory blood low is impaired. Intravenous nitroglycerin (NTG) seems to have no efect on sublingual microcirculation [1], but might have a diferent efect on intestinal perfusion. The aim of this prospective observational sub-study was to evaluate the efect of NTG on intestinal microcirculatory low index (MFI) compared with sublingual MFI in the early phase of sepsis. Methods Eight patients (>18 years) with abdominal sepsis were included. Sublingual and intestinal side-stream dark ield (SDF) images were obtained and MFIs were calculated. Patients received NTG intravenously for 24 hours (2 mg/hour), after fulillment of protocol-driven resuscitation endpoints. Nonparametric tests were used to compare MFI baseline with 24 hours and for comparison within groups. Data are expressed as median (IQR). Results At baseline, sublingual and intestinal MFI did not difer signiicantly (2.2 (1.2 to 1.8) vs 2,7 (1.1 to 2.8), P = 0.89). After 24 hours, sublingual and intestinal MFI were nonsigniicantly higher in comparison with baseline (2.33 (0.48 to 3), P = 0.94 vs 2.75 (2.13 to 2.98), P = 0.67). Furthermore, groups did not difer signiicantly (P = 0.46). However, one patient (number 13) showed a striking decrease in sublingual MFI after 24 hours, whereas intestinal MFI did not change over time. In another patient (number 25), sublingual MFI improved with a concomitant reduction in intestinal MFI over time (Figure 1). Conclusions In this small population of septic patients we could not detect signiicant diferences between the sublingual and intestinal microcirculation in response to NTG after a strict resuscitation protocol. However, in individuals there were marked diferences in absolute values of sublingual and intestinal microcirculatory blood low at baseline and after 24 hours, as well as in diferences over time. These observations on dynamic microcirculatory changes in response to a speciic Figure 1 (abstract P393). MFI with time per patient. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 therapeutic intervention add to previous reports about heterogeneity of microcirculatory blood low in sepsis. Reference 1. Boerma et al.: Crit Care Med 2009. [Epub ahead of print] P394 Diastolic dysfunction in septic shock is an independent predictor of elevated B-type natriuretic peptide and hospital mortality D Sturgess, T Marwick, C Joyce, C Jenkins, M Jones, P Masci, D Stewart, B Venkatesh University of Queensland, Brisbane, Australia Critical Care 2010, 14(Suppl 1):P394 (doi: 10.1186/cc8626) Introduction Diastolic dysfunction as demonstrated by tissue Doppler imaging (TDI), particularly E/E’ (peak early diastolic transmitral/peak early diastolic mitral annular velocity) is common in critical illness. In septic shock, the prognostic value of TDI is undeined. This study sought to evaluate and compare the prognostic signiicance of TDI and cardiac biomarkers (B-type natriuretic peptide (BNP); N-terminal proBNP (NTproBNP); troponin T (TnT)) in septic shock. The contribution of luid management and diastolic dysfunction to elevation of BNP was also evaluated. Methods Twenty-one consecutive adult patients from a multidisciplinary ICU underwent transthoracic echocardiography and blood collection within 72 hours of developing septic shock. Results The mean ± SD APACHE III score was 80.1 ± 23.8. Hospital mortality was 29%. E/E’ was signiicantly higher in hospital nonsurvivors (15.32 ± 2.74, survivors 9.05 ± 2.75; P = 0.0002). Areas under ROC curves were E/E’ 0.94, TnT 0.86, BNP 0.78 and NTproBNP 0.67. An E/E’ threshold of 14.5 ofered 100% sensitivity and 83% speciicity. Adjustment for APACHE III, cardiac disease, luid balance and grade of diastolic function, demonstrated E/E’ as an independent predictor of hospital mortality (P = 0.019). Multiple linear regression incorporating APACHE III, gender, cardiac disease, luid balance, noradrenaline dose, C-reactive protein, ejection fraction and diastolic dysfunction yielded APACHE III (P = 0.033), luid balance (P = 0.001) and diastolic dysfunction (P = 0.009) as independent predictors of lnBNP. Conclusions E/E’ is an independent predictor of hospital survival in septic shock. It ofers better discrimination between survivors and nonsurvivors than cardiac biomarkers. Fluid balance and diastolic dysfunction were independent predictors of BNP concentration in septic shock. P395 Cardiac-speciic troponin I and cardiovascular dysfunction in post-traumatic sepsis G Georgiev, SG Milanov, V Todorova, L Kozarov, M Milanov Pirogov Emergency Institute, Soia, Bulgaria Critical Care 2010, 14(Suppl 1):P395 (doi: 10.1186/cc8627) Introduction Elevated serum levels of cardiac-speciic troponin I (cTnI) are claimed to be associated with the degree of sepsis-related cardiac S133 dysfunction and with the disease outcome in critically ill. We tested this association in a speciic group of ICU patients with post-traumatic sepsis. Methods A prospective observational study was conducted in an ICU of a level I-equivalent trauma center between September 2008 and August 2009. No exclusion criteria were adopted. Serum cTnI concentrations were collected at peak sepsis-related cardiovascular dysfunction (deined by the highest pressure adjusted heart rate (PAR) in MODS score and by the dose of the inotrope). Data were gathered on demographics, severity of inlammatory response (SIRS criteria) and organ dysfunction (MODS score), presence of superimposed acute coronary events, other potential reasons for cTnI elevation and the disease outcome. Intergroup comparisons were made with Student’s t test/nonparametric alternatives. The prognostic utility of cTnI was examined by the construction of ROC curves and its levels were categorized on the basis of the deined cut-of value. Probable associations between these categories and the organ dysfunction severity, as well as the outcome, were examined with Fisher’s exact test. Results A total of 92 polytrauma patients were enrolled. The conidence intervals of PAR, MODS and SIRS were 21.26 ± 2.72, 6.99 ± 2.94 and 3.75 ± 1.10, respectively. Blunt cardiac injury had been diagnosed in 20 patients (21.7%) on admission. Three patients (3.3%) developed acute coronary events during their ICU stay and 12 patients (13.2%) had other potential reasons for cTnI elevation. Signiicantly higher cTnI concentrations were found in the critically ill with myocardial contusion and with acute coronary events. However, the presence of blunt cardiac injury had no measurable outcome efect. Troponin I levels were signiicantly higher in nonsurvivors (P = 0.00) and very good prognostic performance of cTnI was found (AUROC = 0.82; cut-of value = 0.05 ng/ml). The subsequent comparison between its categorized values and those of PAR and MODS showed strong positive association. Elevated cTnI concentrations (>0.05 ng/ml) signiicantly increased the risk of death (RR = 5.58; 95% CI = 1.67 to 20.79; P = 0.002). Conclusions In a group of patients with post-traumatic sepsis elevated serum cTnI levels proved to be a good marker of severe organ (including cardiovascular) dysfunction. They also showed reasonable prognostic value regarding the disease outcome. P396 Both systolic and diastolic functions are impaired in critically ill patients with community-acquired sepsis S Hettwer, M Schürmann, J Wilhelm, H Ebelt, K Werdan Martin-Luther-University, Halle (Saale), Germany Critical Care 2010, 14(Suppl 1):P396 (doi: 10.1186/cc8628) Introduction Alterations in haemodynamic parameters in septic cardiomyopathy are usual. While patients with APACHE II score <15 have a low risk of death, patients with score ≥15 have one of >25%. In a subgroup of our monocentric observational ProFS study (depiction of patients with community-acquired sepsis in the emergency department), systolic and diastolic function were evaluated concerning patients risk of death. Methods Echocardiographic examination was performed at admission, after 24 and 72 hours. The left ventricular systolic ejection fraction (EF, %) Figure 1 (abstract P396). Systolic and diastolic function indices in sepsis. n.s., not signiicant. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 was measured using Simpson’s rule, and early peak diastolic relaxation velocity of septal mitral annulus (E’, cm/second) was measured using tissue Doppler imaging. APACHE II score was calculated at admission. By APACHE II score, two groups were formed: low APACHE II score (LAS) was deined as 0 to 14 patients and high APACHE II score (HAS) ≥15 patients. Results In 65 of 208 patients an echocardiographic examination was performed. Age (61.0 ± 18.4 vs 63.5 ± 16.9 years, P = NS), male sex (64.5% vs 58.8%, P = NS) and mean artery pressure (86.2 ± 15.7 vs 85.7 ± 21.2 mmHg, P = NS) were comparable, whereas patients with HAS had a higher heart rate (96.5 ± 24.5 vs 108.2 ± 17.1/minute, P <0.05). At admission, patients with HAS had a signiicantly lower EF than patients with LAS (55.1 ± 7.0 vs 50.5 ± 10.1, P <0.05). Diference could not be observed after 24 hours (53.6 ± 7.2 vs 52.4 ± 7.%, P = NS) and 72 hours (53.8 ± 7.3 vs 54.3 ± 7.3, P = NS); see Figure 1. Patients with HAS showed a lower initial E’ than patients with LAS (6.2 ± 2.1 vs 5.1 ± 2.1, P <0.05) and after 24 hours (6.1 ± 2.2 vs 5.1 ± 1.3, P <0.05). Three days after admission, E’ values in patients with LAS and HAS were comparable (5.6 ± 2.0 vs 5.7 ± 2.1, P = NS). Conclusions In patients with community-acquired sepsis and APACHE II score ≥15 points, a signiicantly depression of both systolic and diastolic function could be observed. After 24 hours systolic function and after 72 hours diastolic function of patients with an APACHE II score <15 and ≥15 points were similar. This could be possibly due to alterations in afterload. P397 Selective V1a agonism reduces vascular leakage and cardiopulmonary dysfunction in methicillin-resistant Staphylococcus aureus sepsis S Rehberg, P Enkhbaatar, Y Yamamoto, AK Hasselbach, LD Traber, DL Traber The University of Texas Medical Branch, Galveston, TX, USA Critical Care 2010, 14(Suppl 1):P397 (doi: 10.1186/cc8629) Introduction This randomized, controlled experimental trial was performed to compare the efects of the selective V1a-receptor agonist (Phe2Orn8) vasotocin (POV) and the mixed V1a/V2-receptor agonist (Arg8) vasopressin (AVP) on vascular leakage and cardiopulmonary dysfunction associated with methicillin-resistant Staphylococcus aureus (MRSA) pneumonia-induced septic shock using an established ovine model. Methods After instrumentation for chronic hemodynamic monitoring and tracheostomy, sheep were subjected to 48 breaths of cotton smoke (<40°C) and MRSA was placed into both lungs under deep anesthesia. Following a 10 mmHg drop in mean arterial pressure (MAP) from baseline, sheep were randomly assigned to receive intravenous infusions of either POV, AVP or the vehicle (0.9% NaCl; n = 6 each). POV and AVP were titrated to keep MAP above baseline – 10 mmHg. All sheep were awake, mechanically ventilated and luid resuscitated to maintain hematocrit at baseline ±3%. Data are expressed as mean ± SEM at 24 hours. Fluids are represented as the average over time to account for individual survival times. Results Both treatment strategies signiicantly reduced luid input (AVP: 7.7 ± 0.6 ml/kg/hour; POV: 5.8 ± 0.8 ml/kg/hour), positive net luid balance (AVP: 4.9 ± 0.5 ml/kg/hour; POV: 0.4 ± 0.6 ml/kg/hour), thoracic (AVP: 0.8 ± 0.2 ml/kg/hour; POV: 0.3 ± 0.1 ml/kg/hour) and abdominal luid (AVP: 0.10 ± 0.04 ml/kg/hour; POV: 0.01 ± 0.01 ml/kg/hour) as well as extravascular lung water (AVP: 22.6 ± 1.4 ml/kg; POV: 15.8 ± 1.9 ml/ kg) and increased plasma oncotic pressures (AVP: 12.5 ± 0.9 mmHg; POV: 15.9 ± 1.1 mmHg) vs control animals (9.6 ± 0.4 ml/kg/hour; 7.7 ± 0.4 ml/kg/ hour; 2.2 ± 0.4 ml/kg/hour; 0.29 ± 0.13 ml/kg/hour; 22.9 ± 2.8 ml/kg; 8.9 ± 0.1 mmHg, respectively). Notably, POV was superior to AVP in all these variables (P <0.05 each). Myocardial contractility was higher in the POV group vs AVP and control animals as suggested by higher left ventricular stroke work indexes (66 ± 3 vs 48 ± 7 and 43 ± 3 g/m/m2, respectively; P <0.05 each) at lower or similar global end-diastolic volumes. Pulmonary dysfunction (decrease in PaO2/FiO2 ratio) was attenuated in POV (364 ± 47 mmHg) as compared with AVP (195 ± 66 mmHg; P <0.05) and control animals (213 ± 76 mmHg; P <0.05). Whereas one AVP and three control animals had to be sacriiced prematurely, all POV-treated animals survived the 24-hour study period. Conclusions In MRSA pneumonia-induced ovine septic shock, the selective V1a-receptor agonist POV is superior to the mixed V1a/V2receptor agonist AVP in reducing vascular leakage and cardiopulmonary dysfunction when administered as a irst-line vasopressor. S134 P398 Sepsis resuscitation bundle compliance in septic shock: improves survival and yet better late than never V Coba, HFH Sepsis Collaborative Group Henry Ford Hospital, Detroit, MI, USA Critical Care 2010, 14(Suppl 1):P398 (doi: 10.1186/cc8630) Introduction Improvements in survival for acute myocardial infarction, trauma, and stroke have been realized through continuous quality improvement (CQI) initiatives that include early identiication and implementation of time-sensitive therapies at the earliest stage of disease presentation. In addition, challenges in the management of severe sepsis and septic shock remain in regards to implementation of an early sepsis resuscitation bundle (RB) in order to maximize outcome beneit. We examined the impact of a hospital-wide CQI initiative on septic RB compliance and outcome and investigated the mortality beneits beyond the 6-hour recommendation period. Methods Prospective cohort study of patients who met the deinition of severe sepsis or septic shock over an 18-month period. Current sepsis RB being MAP ≥65, CVP ≥8 and SvO2 ≥70% goals met within 6 hours and 18 hours upon presentation. Results The 498 severe sepsis and septic shock patients were enrolled and examined at what time period would the RB still be efective. Using a time cut-of, the Compliers at 18 hours and NonCompliers at 18 hours were then compared. There were 202 patients who had the RB completed in less than or equal to 18 hours (Compliers at 18 hours). There were 296 patients who never completed the RB within 18 hours (NonCompliers at 18 hours). The Compliers at 18 hours had a signiicant 10.2% lower hospital mortality at 37.1% (22% relative reduction) compared with the NonCompliers at 18 hours hospital mortality of 47.3% (P <0.03). Adjusting for diferences in baseline illness severity, the Compliers at 18 hours had a greater reduction in predicted mortality of 26.8% vs 9.4%, P <0.01. Compliance started at 30.4% and inished at 63%. Conclusions A CQI initiative for severe sepsis and septic shock with particular emphasis on the RB signiicantly improved bundle compliance and decreased hospital mortality. It has been previously shown that compliance to the RB within 6 hours improves outcome; however, when the time of bundle completion is extended to 18 hours, the mortality beneits are still signiicant. References 1. 2. Dellinger RP, et al.: Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008, 36:296-327. Rivers E, et al.: Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001, 345:1368-1377. P399 Efect of myocardial preservation of early goal-directed therapy on severe sepsis/septic shock patients in the ICU GL Cai, J Yan, S Qiao Zhejiang Hospital, Hangzhou, China Critical Care 2010, 14(Suppl 1):P399 (doi: 10.1186/cc8631) Introduction To investigate the efect of myocardial preservation of early goal-directed therapy (EGDT) on severe sepsis/septic shock patients in the ICU. Methods This is a prospective and randomized controlled study, in which the total 158 severe sepsis/septic shock patients from the ICU were randomly assigned into two groups (EGDT group, n = 81 and control group, n = 77). Then the concentration of serum cardiac troponin I (cTnI), high sensitivity C-reactive protein (hs-CRP) and APACHE II score of patients were obtained on the 0, 3rd, 7th, and 14th day after luid resuscitation therapy. Results The levels of cTnI were the same between the EGDT and control groups on day 0 (exceeded normal cTnI patients in two groups 0.41 vs 0.42, normal cTnI patients in two groups 0.05 vs 0.04, P >0.05), there was a dramatic decrease in exceeded normal cTnI patients of the EGDT group, in which cTnI returned to normal after EGDT (14th day: exceeded normal cTnI patients in two groups 0.08 vs 0.16, P <0.05); however, only a little diference in normal cTnI patients of the two groups (P >0.05). The level of hs-CRP changed like cTnI (P <0.05), and there was positive correlation between cTnI and hs-CRP on each time (P <0.05); APACHE II scores obviously decrease in the EGDT group (P <0.05). Meanwhile, the EGDT Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 group have an obviously higher 28-day survival rate and longer survival time than that of the control group (74.1% vs 55.8%; 23.5 vs 19.6, P <0.05). Conclusions EGDT has an efect of myocardial preservation and improves the survival rate for severe sepsis/septic shock patients in the ICU. References 1. 2. Richard S, Hotchkiss RS, Karl IE, et al.: The pathophysiology and treatment of sepsis. N Engl J Med 2003, 348:138-150. Rivers E, Nguyen B, Havstad S, et al.: Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001, 345:1368-1377. P400 Impact of the sepsis bundle strategy on the outcomes of the patients sufering from severe sepsis and septic shock Z Wang Beijing Shijitan Hospital, Beijing, China Critical Care 2010, 14(Suppl 1):P400 (doi: 10.1186/cc8632) Introduction Patients sufering from severe sepsis and septic shock have a high mortality. Studies have demonstrated that the septic bundle strategy decreased the mortality of severe sepsis and septic shock. The aim of this study was to compare the impact of the sepsis bundle strategy on the outcomes of the patients sufering from severe sepsis and septic shock in our emergency department. Methods A prospective study was performed. The studied population included severe sepsis and septic shock patients entered into the Surviving Sepsis Campaign (SSC) database, who were admitted to the emergency department of an urban tertiary-care medical center during June 2008 to June 2009. They were divided into two groups based on the admission time (Group 1: June 2008 to December 2008, baseline survey of real practice in sepsis therapy before creating a protocol. Group 2: January 2009 to June 2009, creating a protocol implementing sepsis resuscitation bundle in sepsis therapy). Acute Physiology and Chronic Health Evaluation (APACHE II) scores, treatments and in-hospital mortality were compared. Results The timing giving broad-spectrum antibiotics of ED admission was 3.67 hours in Group 1 and 2.52 hours in Group 2 (P <0.01). Blood cultures before antibiotics administration was 39.7% in Group 1 and 56.3% in Group 2 (P <0.01). Fluid bolus (20 ml/kg) delivered followed by vasopressors if needed was 27% in Group 1 and 76% in Group 2 (P <0.01). In-hospital mortality was 44.8% in Group 1 and 35.6% in group, in-hospital mortality decreased by 9.2% (P <0.01). Conclusions Creating a protocol implementing sepsis bundles improved compliance for the bundle strategy on the treatment of severe sepsis and septic shock and decreased in-hospital mortality. P401 Impact of Surviving Sepsis Campaign implementation in Brazil F Machado, A Pereira, C Silva, P Schippers, E Ferreira, N Akamine, M Assuncao, BF Mazza, R Costa Filho, H Fernandes, C Grion, M Oliveira, MO Maia, E Silva Latin America Sepsis Institute, São Paulo, Brazil Critical Care 2010, 14(Suppl 1):P401 (doi: 10.1186/cc8633) Introduction Sepsis mortality rates in Brazil are high [1,2]. Many studies have already shown that implementation of education programs based on Surviving Sepsis Campaign 6-hour (6h SSC) and 24-hour bundles successfully reduces sepsis mortality. The objective of this study was to evaluate the impact of the SSC-based program on patient outcome in Brazil. Methods Severe sepsis and septic shock patients were included in voluntary participating hospitals that have sent data for at least 2 years. The intervention was based on strategies aimed at improving compliance with the bundles. Regular reports containing compliance and mortality data were sent to the hospital in order to base local strategies of improving care. Results are presented by the semester of hospital inclusion in the campaign through 2 years, regardless of when those months occurred in the time frame of the study. Results were considered signiicant if P <0.05. Results From February 2005 and August 2009, 19 hospitals included 2,135 patients in a nonconcomitant fashion. Demographic data are restricted as in the SSC database. Septic shock patients comprised 52% of the patients with a mean number of organ dysfunctions of 2.34 ± 1.33, and 38.6% were admitted from the ER and 24.9% developed sepsis during their ICU stay. S135 Compliance to 6h SSC increased from the irst to the fourth semester as follows: lactate: 65.0% to 71.5%, P = 0.01, blood culture: 42.5% to 50.3%, P = 0.08, antibiotics: 38.9% to 45.3%, P = 0.02, achieving mean arterial pressure >65 mmHg: 43.7% to 75.4%, P <0.000, CVP achievement: 14.6% to 36.6%, P <0.000, SvO2 achievement: 10.4 to 22.7, P = 0.000 and completion of the whole bundle: 8.3 to 9.0, P = 0.34. A 7% absolute reduction (relative reduction of 11.6%) in hospital mortality was found in the third semester of the campaign (OR 1.33 (1.04 to 1.69), P = 0.01). However, in the fourth semester mortality has increased again to 60.6%. Conclusions Implementation of the SSC in Brazil has been associated with increased bundle adherence. However, the impact on the mortality rate seems not to be sustained, probably due to the diiculty associated with keeping an education program. It is important to develop strategies aiming to increase motivation in Brazilian hospitals. References 1. 2. Silva E, et al.: Crit Care 2004, 8:R251-R260. Sogayar AM, et al.: Pharmacoeconomics 2008, 26:425-434. P402 Efect of synthetic vasopressin in septic shock using eosphageal Doppler H Elatroush, N Abed, F Ragab, M Aify Cairo University, Cairo, Egypt Critical Care 2010, 14(Suppl 1):P402 (doi: 10.1186/cc8634) Introduction Noradrenaline and dopamine were the standard catecholamines used in the treatment of septic shock. Loss of response was the common problem that led to patient loss after large continuous doses of noradrenaline, which was termed catecholamine refractory septic shock. Recently vasopressin and its analog, namely terlipressin, were used in the treatment of such a catastrophic condition. Methods In a prospective controlled study we included 40 patients with catecholamine-resistant septic shock (that is, noradrenaline dose exceeded 0.6 μg/kg/minute) divided into two groups: 20 patients were treated conventionally according to the Surviving Sepsis Campaign 2008, who served as a control group; and the other 20 patients were treated conventionally and when the noradrenaline dose exceeded 0.6 μg/kg/ minute, terlipressin in a dose of 1 mg intravenous bolus every 12 hours for a study time of 48 hours was started. Results Terlipressin therapy was associated with increased systemic vascular resistance from 546 ± 260 dyne·sec/cm–5 to 986 ± 390 dyne·sec/ cm–5 after 48 hours, which represents normalized arterilor tone that is expected to allow better organ bed perfusion. There was a reduction of both stroke volume and cardiac output (from 63 ± 16 ml/beat to 51 ml/ beat and from 78 l/minute to 5.3 l/minute, respectively) yet this was not associated with abnormal organ perfusion marked by improved urine output from 49 ml/hour to 133 ml/hour and improved global perfusion as marked by decrease lactic acidosis from 9.3± 3 mEq/l to 5.7 ± 3 mEq/l, P <0.002. There was signiicant reduction of oxygen delivery (DO2 from 848 ml/minute to 610 ± 47 ml/minute after 48 hours, P >0.02). There was no efect on length of ICU stay in both groups (16 ± 6 days in the terlipressin group and 12 ± 6 days in control group, P <0.06). Terlipressin support showed nonsigniicantly less mortality (60% vs 70% in control group). Regarding organ function, terlipressin could improve the SOFA score from 11 ± 3.2 to 8 ± 5 with P <0.02. Conclusions Terlipressin is a rather safe, inexpensive, easy to administer alternative in the treatment of septic shock. Further studies are needed to decide the ideal timing for initiation of this therapy early vs late adjuvant or as an initial treatment. Reference 1. Vincent JL: Crit Care Clin 2006, 22:187-197. P403 Efects of sepsis resuscitation bundle in cirrhotic patients with septic shock L Rinaldi, E Ferrari, D Trevisan, L Donno, M Girardis Policlinico di Modena, Italy Critical Care 2010, 14(Suppl 1):P403 (doi: 10.1186/cc8635) Introduction The efectiveness of the interventions recommended by the Surviving Sepsis Campaign (SSC) guidelines [1] has never been tested Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 in patients with speciic co-morbidities such as chronic liver disease. In this study we evaluated whether the adherence to the resuscitation sepsis bundle improved the outcome of cirrhotic patients with septic shock admitted to the ICU. Methods The prospective observational cohort study included 38 patients with documented cirrhosis and septic shock admitted to a multidisciplinary ICU at a university hospital from January 2005 to June 2009. In each patient the compliance to four resuscitation interventions recommended by the SSC guidelines (that is, 6-hour bundle) and the 30-day mortality were measured. Results The 6-hour bundle was completed in 50% of the patients. In these patients the MELD and SOFA scores (39 ± 11 and 18 ± 2) were higher (P <0.05) than those observed in patients without compliance to the 6-hour bundle (31 ± 12 and vs 15 ± 3). The 30-day mortality was 94.7% and 68.4% (P <0.05) in patients with and without 6-hour bundle compliance, respectively. A Cox regression analysis, after adjustment for MELD and SOFA scores, indicated that none of the single sepsis interventions as well as the 6-hour bundle was independently associated with 30-day survival. Conclusions The adherence to the resuscitation interventions recommended by the SSC evidence-based guidelines did not improve the survival rate of cirrhotic patients with septic shock admitted to our ICU. Reference 1. Dellinger RP, et al.: Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008, 36:296-327. P404 Outcomes and incidence of bleeding events associated with drotrecogin alfa: a single-centre experience of 440 patients A Boyle, C McKenzie, S Yassin, A McLuckie, D Wyncoll Guy’s and St Thomas’ NHS Trust, London, UK Critical Care 2010, 14(Suppl 1):P404 (doi: 10.1186/cc8636) Introduction Although drotrecogin alfa activated (DAA) was approved in 2002 for the treatment of severe sepsis, controversy has surrounded this therapy especially with respect to the increased risk of serious bleeding events (SBEs). Recently, there has been further interest in the complications of DAA following a review by Gentry and colleagues suggesting a signiicantly increased incidence of SBEs and death in those with baseline bleeding precautions [1]. We are one of the largest single-centre users of DAA worldwide and thus are keen to report our experience. Methods In 2002 a scoring system, reporting tool, and supporting database were developed to track the outcome of DAA-treated severe sepsis patients in our hospital. This is maintained by the clinical pharmacists and captures data on relative contraindications, adverse events and patient outcome. Classiication of data is obtained from the electronic patient record. Any DAA administration outside agreed criteria is recorded and bleeding incidents are reviewed with a consultant intensivist to conirm categorisation into serious or minor. Results Four hundred and forty patients, including some enrolled in clinical trials, received DAA in our critical care unit over a 7-year period (2003 to 2009). The mean age was 63 years (range 17 to 92). Four hundred and twenty-eight (97.3%) patients met agreed criteria for treatment. Twelve (2.7%) were treated despite being in single organ failure. Mean organ dysfunction was 3.3 and over 75% of patients had at least three organ failures. The commonest sites of infection were respiratory (56%), abdominal (29%) and urinary tract (4%). The 28-day, critical care and hospital mortalities were 35%, 39% and 46%, respectively. Relative contraindications (CIs) were identiied for 38 (8.6%) patients treated with DAA. Of these, 23 (5.2%) had an increased baseline bleeding risk, most commonly thrombocytopenia (2%). Hospital mortality for patients with any CI was 47% (n = 18) and 48% (n = 11) if existing predisposition for bleeding. In the 440 patients, 67 (15%) bleeding events were reported, but only 19 (4%) were considered SBEs (using the deinitions from PROWESS [2]). Overall mortality for all bleeding events was 57% and 74% for patients with SBEs. Administration errors occurred in 34 (7.7%) patients, of which three (0.7%) were considered serious. Three hundred and eighteen (72%) patients received DAA for at least 72 hours. Of those who did not complete the course, 81 (66%) died. Conclusions We have observed a low incidence of SBEs in patients treated with DAA. As expected, SBEs were associated with a poorer outcome. S136 We irmly believe an established scoring system and monitoring tool has facilitated efective use of DAA whilst minimising associated risks of therapy. References 1. 2. Gentry C, et al.: Crit Care Med 2009, 37:19-25. Bernard G, et al.: N Engl J Med 2001, 344:699-709. P405 Activated protein C: cost matters! T Dravid, B Pawar, B Bhurke, P Akole, P Rajhans, S Jog Deenanath Mangeshkar Hospital, Pune, India Critical Care 2010, 14(Suppl 1):P405 (doi: 10.1186/cc8637) Introduction Activated protein C (APC) is an efective treatment in multiorgan failure (MOF) due to severe sepsis. Recommended duration of treatment of APC is 96 hours infusion. The cost of APC infusion for 96 hours in a 60 kg person is an average INR 490,000 in India (€7,000) (€1 ~ INR 70 in November 2009, average value) whereas the average cost of 10 days of ICU treatment for a patient with sepsis with MOF, all inclusive, is approximately INR 140,000 in our hospital (€2,000). It is unclear whether stopping APC before 96 hours, in patients in whom MOF resolves before 96 hours, ultimately afects the inal outcome in terms of survival. This is more relevant in developing countries like India where the cost of 96 hours of infusion of APC is beyond the reach of the majority of patients eligible for it. We retrospectively analysed the cost savings achieved by early stoppage of APC ensuring MOF reversal, before completion of the recommended 96 hours infusion. Methods During a period of 3 years, patients with severe sepsis having ≥3 organ failures were ofered the option of APC. For those who opted for it, infusion was initiated within 24 hours of onset of MOF. APC infusion was stopped before completion of 96 hours only if septic shock, ARDS and coagulopathy was completely resolved, otherwise it was continued for 96 hours. Results Two hundred and thirteen patients with severe sepsis having MOF were ofered the option of APC infusion. Twenty patients opted for it. In seven patients APC was infused for 96 hours as per the standard recommendation. In 13 patients APC infusion could be stopped before 96 hours assuring complete reversal of MOF. They were enrolled in our study. Eleven out of 13 patients were discharged home after complete recovery. MOF did not reappear in any of these 13 patients. Two patients developed a new episode of ventilatory-associated pneumonia on day 4 and day 10, respectively, after stopping the infusion of APC and could not be salvaged. Average duration of APC infusion was 70.33 ± 20.76 hours. Cost of APC infusion per patient for average 70 hours was INR 347,692 ± 38,330 (€4,967). Duration of ICU stay (average) was 11.61 ± 5.18 days. Average cost of ICU care for 11 days (excluding cost of APC) per patient was INR 144,272 ± 86,754 (€2,061). The cost saving achieved due to early stoppage of APC (per patient) was INR 132,708 ± 42,330 (€1,895). Conclusions Stopping APC infusion before 96 hours in patients who show rapid reversal of MOF is associated with signiicant cost saving without compromising the survival outcome. With this judicious early stoppage strategy, a greater number of patients can aford this efective drug. P406 Outcome of patients receiving two or more infusions of activated protein C: a single-centre experience A Retter1, S Lippett2, R Beale1, D Wyncoll1 1 Guy’s and St Thomas’ NHS Trust, London, UK; 2Royal Sussex County Hospital, Brighton, UK Critical Care 2010, 14(Suppl 1):P406 (doi: 10.1186/cc8638) Introduction Patients frequently develop a second discrete episode of sepsis during an ICU stay such as ventilation-acquired pneumonia (VAP), or patients may have a second ICU admission unrelated to their initial presentation. In the PROWESS [1] study, drotrecogin alfa (DAA) could not be given twice to the same patient; yet this may be a potentially life-saving intervention when a second episode of severe sepsis occurs. Methods We conducted a retrospective study of patients who received more than one infusion of DAA in our combined adult surgical and medical ICU. The attending ICU physician determined who received a second course of DAA. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S137 Results During the 6-year study period (November 2002 to October 2008) 354 patients were treated with DAA, seven patients were identiied who received DAA twice and one patient received three infusions. Five patients treated with two infusions survived to be discharged home. Four patients were admitted to the ICU on two separate occasions, for these patients one infusion of DAA was given on each admission, three survived, and the median interval between admissions was 17 months (range 7 to 23). Four patients received a second infusion of DAA on the same ICU admission, the median interval between the irst and second infusion was 3.5 days (range 3 to 12), and two survived. The median age was 67 years (range 41 to 77) with a median of four organ failures per patient (range 2 to 5). Those patients who received DAA twice on the same admission developed VAP or a line-related infection. Patients admitted for a second time had a diferent discrete episode of septic shock unrelated to their irst admission. There was one major bleeding episode requiring cessation of DAA and a blood transfusion. This patient was found to have a duodenal ulcer. Six infusions of DAA were not completed, three patients died whilst receiving their second infusion, three courses were terminated due to rapid improvement in the patient’s condition. No patient experienced signiicant bleeding during their second infusion. Conclusions This is the irst case series to report the outcome of patients who have received multiple courses of DAA. The incidence of repeat episodes of sepsis during a single admission or the precise rate of recurrent sepsis during ICU admissions is not easily identiied in the current literature. Our indings are limited by the heterogeneous nature of the patient group and the lack of strict criteria deining who received a second course of DAA. A second course of DAA treatment may be justiied on a case-by-case basis. Reference 1. Bernard GR, et al.: N Engl J Med 2001, 344:699-670. P407 Drotrecogin alfa (activated): a single-centre experience of 110 patients S Fletcher, N Pathmanathan Bradford Teaching Hospitals, Bradford, UK Critical Care 2010, 14(Suppl 1):P407 (doi: 10.1186/cc8639) Introduction We present our experience with drotrecogin alfa (activated protein C (APC)) over 4 years (2005 to 2008) in 110 patients and compare the indings with a large UK audit [1]. Methods Data were collected on diagnosis, acuity, complications and outcomes. Survival was assessed using standardised mortality ratios. Results One hundred and ten patients received APC. Two patients had two courses. Fifty-six per cent of patients received APC in the irst 24 hours of ICU stay; 88% within 48 hours. Sixty-eight per cent of patients completed the 96-hour course; 20% died during the infusion; 5% had APC stopped because of resolution of severe sepsis. Crude ICU mortality was 47%; 9% died after ICU discharge. Survival to hospital discharge was 44%. The SMRs were 1.21 (95% CI 1.02 to 1.41) using APACHE II and 1.05 (0.88 to 1.22) using the ICNARC method. Three patients had cerebral haemorrhage. Three had cerebral thrombotic events. There were no other cases of signiicant haemorrhage. APC usage fell over the study period 2005 to 2008 with 37, 35, 26 and 14 patients per year, respectively. similar to predicted. Rates of serious complications appeared to be similar to those experienced elsewhere. The fall in APC usage over time relects uncertainty over its risk–beneit proile. Reference 1. Rowan KM, et al.: Crit Care 2008, 12:R58. P408 Eicacy of recombinant human soluble thrombomodulin in disseminated intravascular coagulation T Yasuda, N Kiyonaga, T Ohryorji, M Nakahara, N Okayama, T Kikuchi, T Imabayashi, Y Kakihana, Y Kanmura Kagoshima University Hospital, Kagoshima City, Japan Critical Care 2010, 14(Suppl 1):P408 (doi: 10.1186/cc8640) Introduction Soluble thrombomodulin is a promising therapeutic natural anticoagulant that is comparable with antithrombin, tissue factor pathway inhibitor and activated protein C. Recently, a recombinant human soluble thrombomodulin, composed of the active, extracellular domain of thrombomodulin, has become commercially available for patients with disseminated intravascular coagulation (DIC). However, its efect on adhesion molecule or plasminogen activator inhibitor 1 (PAI-1) in patients with DIC is not clear. To elucidate the possible efect of a soluble thrombomodulin on endothelial cell and neutrophil interaction in DIC, we investigated the eicacy of a recombinant human soluble thrombomodulin against not only soluble ibrin (SF) for the sensitive marker of DIC, but also soluble E-selectin (sES) and PAI-1 in patients with DIC. Methods We studied 33 patients with DIC associated with sepsis. DIC was diagnosed according to the diagnostic criteria established by the Japanese Association for Acute Medicine. Seventeen of 33 patients (RTM group) were assigned a recombinant human soluble thrombomodulin for 6 consecutive days. SF, sES, and PAI-1 were measured at day 0 (before treatment), and day 7. DIC resolution rate, clinical course of bleeding symptoms, and survival rates at 90 days were evaluated. Data were subjected to Mann–Whitney U test, Kaplan–Meier method and log-rank test (P <0.05 being considered statistically signiicant). Results The baseline characteristics at study entry in both groups (17 treated and 16 control) were almost similar. There were no signiicant diferences of the serum values of platelet, FDP, D-dimer and PAI-1 between two groups. However, sES and SF values in the RTM group were signiicantly decreased from 43.9 ± 31.2 (at day 0) to 29.46 ± 15.08 μg/ ml (at day 7) (P = 0.044) and from 44.6 ± 35.5 (at day 0) to 18.5 ± 16.6 μg/ ml (at day 7) (P = 0.039), respectively. Also both the DIC score and SOFA score improved signiicantly. There was no incidence of bleeding-related adverse events up to 7 days after the start of infusion in the RTM group. Survival rates at 90 days were 58.8% (RTM group) vs 25.0% (Control group). Conclusions In patients administered with recombinant human soluble thrombomodulin, sES and SF decreased and the DIC score and SOFA score improved signiicantly. There was no signiicant diference between the thrombomodulin group and Control group in survival rate, but there was a tendency that the RTM group had higher survival rate in comparison with the Control group. Reference 1. Saito H, et al.: J Thromb Haemost 2007, 5:31-41. Table 1 (abstract P407). Patient characteristics Age 57 ± 16 Male sex 53% APACHE 21 ± 6 ICNARC Organ failures Postop 29 ± 7.3 5 (4 to 5 IQR) 38% Conclusions Our results are similar to those of a UK-wide audit of APC usage [1]. The mortality of our patients was higher (56% vs 45%), but our patients were probably sicker (median ive organ failures vs three). Based on APACHE, actual outcome appears worse than predicted for patients receiving APC. Using the ICNARC method score, however, outcomes were P409 Clinical experience with lipopolysaccharide adsorber in cancer patients with severe sepsis and septic shock E Gromova, M Kisselevskiy, N Anisimova, L Kuznetsova Cancer Research Center, Moscow, Russia Federation Critical Care 2010, 14(Suppl 1):P409 (doi: 10.1186/cc8641) Introduction Sepsis is one of the most often met complications for cancer patients. It is caused by immunosuppression after radiotherapies and chemotherapies as extensive operations. For sepsis treatment, many experts now recommend even more often using extracorporeal detoxiication methods. Since sepsis is more often caused by Gramnegative microorganisms in clinical hospitals, lipopolysaccharide (LPS) adsorption was ofered for treatment of the patients. Methods For extracorporeal detoxiication of cancer patients with severe Gram-negative sepsis and septic shock (APACHE II score 28 ± 7 on starting Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 hemoperfusion) we used LPS adsorber (Alteco® LPS Adsorber; Alteco Medical AB, Lund, Sweden). The patient’s blood was taken before and after adsorption, then the serum was separated and stored at –70°C. We determined the LPS concentration by LAL test, lipopolysaccharide-binding protein (LBP), sIL-1 RII and sCD14 by ELISA kits (Hycult Biotechnology, the Netherlands), and proinlammatory and anti-inlammatory cytokines IL6, TNFβ, IL-8, IL-2, INFγ, IL-12, TNFα, IL-4, IL-5, IL-1β and IL-10 by ELISA kit (Bender MedSystems). Results In all cases we saw reliable reduction of the LPS level in serum (1.8 to 2 times). After the investigation of some cytokine levels we obtained similar results: IL-6, TNFβ and IL-8 levels had been reduced 30 to 40%, 87% and 62 to 76% accordingly. At the same time, IL-2, INFγ, IL-12, TNFα, IL-4 and IL-5 levels in serum had not changed practically. However, in approximately 1/3 cases an IL-1β and IL-10 concentration increase in serum was observed (33 and 40% accordingly). Also our research has shown that, in the most of the cases after application of this sorbent, LBP decreased insigniicantly (10 to 32%), but the sIL-1 RII level slightly increased (10 to 18%) in the majority of patients and considerably decreased (two times) in 1/3 investigated patients. The CD14 concentration in patient serum reliably did not change before and after adsorption. The somatic status of patients was stabilized after LPS adsorption. Conclusions After LPS adsorption with Alteco® the LPS level in patient serum signiicantly reduced. Simultaneously, concentrations of some cytokines (IL-6, TNFβ, IL-8) were reliably decreased. But the LPS adsorber probably does not eliminate soluble receptors like sCD14 and RIL-1 from blood. So the LPS adsorption may represent a signiicant improvement in the treatment of cancer patients with severe Gram-negative sepsis and septic shock. P410 Apheresis of activated leukocytes with an immobilized polymyxin B ilter N Takeyama1, T Kumagai1, M Harada1, Y Kajita1, Y Miki1, H Kanou2, Y Inoue1, T Nakagawa1, H Noguchi2 1 Aichi Medical University, Aichi, Japan; 2Fujita Health University, Toyoake, Japan Critical Care 2010, 14(Suppl 1):P410 (doi: 10.1186/cc8642) Introduction It was assumed that pathologic activation of neutrophils and monocytes is associated with sepsis, acute lung injury/ARDS, and multiple organ failure, and that removal of these cells from the circulation could reduce leukocyte-dependent tissue injury. Cartridges containing polymyxin B (PMX) immobilized to ibers (Toraymyxin; Toray Industries, Tokyo, Japan) have been developed for selective adsorption of circulating endotoxin in patients with Gram-negative bacterial infection, and this treatment has proven to be highly efective. This study examined the efect of direct hemoperfusion through ilters with immobilized PMX direct-hemoperfusion (DHP) on leukocyte function and plasma levels of cytokines in patients with septic shock. Methods We evaluated the efect of PMX-DHP on circulating leukocytes in patients with septic shock by assessing the changes of neutrophil and monocyte surface antigen expression after PMX-DHP. In another experiment, heparinized blood from patients with sepsis was passed through PMX ilters in a laboratory circuit and then changes of the cell count and surface antigen expression by neutrophils and monocytes were assessed. After perfusion, neutrophils were isolated and the capacity of these cells to damage cultured endothelial monolayers was also determined. Results We found that PMX-DHP led to an increased CXCR1 and CXCR2 expression along with a decrease of CD64 and CD11b expression by circulating neutrophils from septic patients. Plasma levels of cytokines, including IL-6, IL-8, IL-10, and high-mobility group box-1, were elevated in patients with septic shock compared with healthy controls, but cytokine levels were not altered by PMX-DHP. Ex vivo perfusion of heparinized blood from patients with sepsis through PMX ilters in a laboratory circuit caused a signiicant decrease of the neutrophil and monocyte counts. Activated neutrophils with high CD11b/CD64 expression and low CXCR1/CXCR2 expression showed preferential adhesion to PMX ilters. Neutrophils isolated from the blood after ex vivo PMX perfusion caused less damage on the endothelial cell monolayer than cells from sham-treated blood. S138 Conclusions PMX-DHP inluences neutrophils via a mechanism that does not involve cytokines. Ex vivo results indicate that PMX-DHP selectively removes activated neutrophils and reduces the ability of circulating cells to cause endothelial damage. Selective removal of activated neutrophils by PMX-DHP may contribute to improvement of the systemic inlammatory reaction in septic patients. P411 Therapeutic blood puriication using functionalized core/shell nanomagnets IK Herrmann1, M Urner2, FM Koehler1, B Beck Schimmer2, WJ Stark1 1 ETH Zurich, Switzerland; 2University Hospital Zurich, Switzerland Critical Care 2010, 14(Suppl 1):P411 (doi: 10.1186/cc8643) Introduction Direct and rapid removal of pathogens or noxious metabolites from a patient is the most straightforward cure imaginable. Dialysis and plasma iltration/exchange are the current broadly applicable methods to perform a direct removal of disease-causing factors from a patient. We describe the use of stable nanomagnets to rapidly and selectively remove heavy metal ions, overdosed steroid drugs and proteins from human blood. This nanomagnet-based puriication method avoids fouling of ilter membranes and beneits from a high external surface area, and a correspondingly fast difusion. Methods Nanomagnets equipped with heavy metal complexants, digoxin antibody fragments and entire human IL-6 antibodies were added to a series of blood samples. The nanomagnets scan blood by Brownian motion and capture their target. Afterwards, a small magnet was placed at the sample tube wall accumulating the nanomagnets in the pole region of the external magnet. The puriied supernatant can then easily be decanted. The concentrations of lead, digoxin and IL-6 in blood samples were determined by standard clinical methods. Blood integrity was observed by rotation thromboelastography and monitoring of serum potassium, lactate dehydrogenase, bilirubin and haptoglobin levels. To measure the biological relevance of the IL-6 removal, the efect on caspase-3 activation was assessed in camptothecin-stimulated neutrophils. Results A signiicant decrease of lead, digoxin and IL-6 levels was measured after the blood puriication procedure. The extraction using nanomagnets was in clear dose–efect dependence and could be accurately titrated. Treatment with nanomagnets did not signiicantly afect the integrity of blood and all levels remained in the clinical norm range. Caspase-3 assays showed a reduced anti-apoptotic efect after IL-6 removal, underlining the biological relevance of the achieved removal eiciency. Conclusions We demonstrate the extraction of lead, digoxin and IL-6 from whole blood as an example for the rapid treatment of heavy metal poisoning, drug overdosing and severe inlammation. The presented direct blood extraction could be combined with existing therapeutic strategies and may have major implications on the treatment of severe intoxications, sepsis (speciic iltering of cytokines or toxins) [1], metabolic disorders (thyreotoxicosis) and autoimmune diseases. References 1. Ronco C, et al.: N Engl J Med 2003, 348:1600-1602. P412 Coupled plasma iltration and adsorption in septic shock: a multicentric experience F Turani1, M Falco1, S Natoli2, F Leonardis2, M Fede2, G Berlot3, M Pelichovskà3 1 European Aurelia Hospital, Rome, Italy; 2University of Tor Vergata, Rome, Italy; 3 University of Trieste, Italy Critical Care 2010, 14(Suppl 1):P412 (doi: 10.1186/cc8644) Introduction Recently extracorporeal removal of mediators and endotoxins improved haemodynamics, organ dysfunction and mortality in patients with abdominal sepsis [1]. Coupled plasma iltration and adsorption (CPFA), too, may improve haemodynamics, respiratory function and mortality through removal of proinlammatory mediator. The aim of this multicentric study is to evaluate the haemodynamic response and the respiratory function, and to evaluate the reduction of inlammatory markers during CPFA. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S139 Methods Fifty-ive septic patients were enrolled in this study. Every patient had four CPFA treatments (LINDA; Bellco-Mirandola, Italy) for 8 hours with Qb = 200 ml/minute, Qultrailtration = 30 ml/kg/hour and Qplasma = 20% of Qb. At T0 (basal), T1 (after irst cycle), T2 (after second cycle), T3 (after third cycle) and T4 (after fourth cycle) we evaluated haemodynamic parameters, norepinephrine dosage, PaO2/FiO2 ratio, plasma IL-6, and procalcitonin (PCT). The ANOVA test was used to compare changes during times study. P <0.05 was considered statistically signiicant. Results Patients enrolled in the study have been submitted to 256 CPFA treatments for 2,650 hours. Table 1 presents the main results of the study. IV quartile of IL-6 is shown in Table 1. Table 1 (abstract P412) T0 T4 IL-6 (pg/ml) 850 ± 127 125 ± 28* PCT (pg/ml) 45 ± 9 6 ± 2** 0.35 ± 0.09 0.08 ± 0.05** 198 ± 28 310 ± 92** Noradrenaline (μg/kg/min) PaO2/FIO2 *P <0.05, **P <0.01 vs T0. Conclusions In this large multicentric study, CPFA may improve haemodynamic status and respiratory function. Plasma iltration and adsorption of proinlammatory mediators may explain this improvement. Larger randomized controlled trials are indicated to conirm these data. Reference 1. Cruz D, et al.: JAMA 2009, 23:2445-2452. P413 Patients admitted to the ICU for extra-abdominal disease and operated on for emergency laparotomy have signiicant survival C Lentschener, J Beranger, J Charpentier, Y Ozier, J Mira Cochin Hospital, Paris, France Critical Care 2010, 14(Suppl 1):P413 (doi: 10.1186/cc8645) Introduction Limited data are available concerning patients admitted to the ICU for an extra-abdominal disease and operated on for emergency laparotomy (EL) [1]. We investigated whether such patients had beneit from EL and factors likely to predict survival. Methods EL was performed in 48 ICU patients admitted for an extraabdominal disease over the year 2008. The following variables were compared between survivors (discharged alive from hospital) and nonsurvivors: (a) sex ratio, BMI; (b) pre-existing co-morbidities considered in seven additive categories: cardiac, respiratory, renal, gastrointestinal, hepatic, diabetes, malignancies, and corticosteroid therapy; (c) preoperatively: IGS II score, mechanical ventilation (MV), vasopressor use, extra-renal epuration requirement, abdominal signs (obstruction, tenderness, contracture, compartment syndrome), records of computed tomography (CT) and ultrasonography examinations; (d) intraoperative indings deined as perforation, infection, ischemia or necrosis of a visceral organ, pancreatitis, bowel obstruction, biliary disease, no inding. The t, Mann–Whitney U, and chi-square tests (P <0.05), and multiple regression analysis (P <0.1) were used. Results Twenty-six patients (58%) survived. EL was decided because of abdominal signs in 35 patients, lack of improvement of one or several organ failures in 44 patients, speciic signs on CT scan, and/or ultrasound examination (active bleeding, subphrenic collection, bowel obstruction, pneumoperitoneum) in 22 patients, or nonspeciic signs in 29 patients. EL did not identify any surgical cause in 10 patients. Groups did not difer in intraoperative indings (P = 0.2), preoperative creatinine level (P = 0.3), and preoperative anuria requiring extra-renal epuration (P = 0.2). Groups difered in preoperative MV (P = 0.04), vasopressor requirement (P = 0.02), lactate levels (P = 0.03), IGS II (P = 0.0003), and pre-existing co-morbidities (P = 0.04). No such correlation was found in multivariate analysis (all P >0.15). Conclusions Neither clinical nor laboratory variables, or operative indings predicted death following EL. The survival rate was high enough to warrant surgical EL for suspected intra-abdominal focus. Reference 1. Sutherland FR, et al.: J Trauma 1989, 29:1982-1986. P414 Can ICU admission be predicted? L Orwelius, M Fredriksson, C Bäckman, J Persson, F Sjöberg Faculty of Health Sciences, Linköping, Sweden Critical Care 2010, 14(Suppl 1):P414 (doi: 10.1186/cc8646) Introduction After intensive care (IC), patients report poor health-related quality of life (HRQoL). Many factors afect the patients and inluence the HRQoL after discharge. One of these factors is the patient’s health status before the critical care period. In a previous study we found that the IC patients have a high frequency of pre-existing diseases. However, it is unknown to what extent these pre-existing diseases afect the consumption of hospital resources (measured as days as inpatients) in the time period before admission to the ICU and during the years following it. The consumption prior to the ICU event may also be claimed to herald an increased risk for a later ICU admittance? The aim of this study was to examine the hospital care consumption of former ICU patients 3 years prior to and 3 years after the intensive care period. This was examined in relation to the pre-existing health status. Methods Two mixed ICUs from hospitals in two cities in Sweden. A questionnaire including previous illnesses and HRQoL scale SF-36 were sent 6, 12, 24 and 36 months after discharge from the ICU and hospital. All adult patients with an ICU stay >24 hours were included. The institutional care consumption was assessed from the regional hospital databases Results Six hundred and thirteen patients were included in the study. Of these 73% had pre-existing diseases. There were no signiicant diferences between the previously healthy patients apart from younger age (mean age 52 (SD 20.7) vs 60 (SD 17.3)) and lower APACHE II scores (13.4 (SD 7.2) vs 16.4 (SD 7.7)) compared with patients with pre-existing disease. The ICU patients with pre-existing disease consumed signiicantly more hospital resources 3, 2 and 1 year prior to admission to the ICU, and up to 3 years after discharge both regarding quantity of care (number of visits) (P = 0.001), length of stay (P = 0.001), and cost (P = 0.002). There were no signiicant diferences in quantity of care, length of stay, or costs during the ICU period. Most importantly there was a signiicant increasing trend for the 3 years prior to the ICU event. Conclusions Patients with co-morbidities have a signiicant consumption of hospital resources both prior to and after the ICU period. Interestingly, this consumption increased prior to the ICU event and seemed to herald the future deterioration of the patients. Further investigations should be made to examine to what extent ICU admissions can be predicted based on these data. Reference 1. Orwelius L, et al.: Crit Care Med 2005, 33:1557-1564. P415 Unsuitable for ICU: what happens next? A McKeown, L Strachan, P Keeley, MG Booth, A Calder, A Panicker Glasgow Royal Inirmary, Glasgow, UK Critical Care 2010, 14(Suppl 1):P415 (doi: 10.1186/cc8647) Introduction This observational prospective study examined the outcomes and symptoms in those patients who are unsuitable for ICU admission. Methods All patients referred to ICU for admission but deemed unsuitable were recorded by the team. These patients were reviewed by palliative care researchers. Demographic information (age, sex, diagnosis) and data on patient’s symptoms of progress and outcome were collected at four time points (24, 48, 72 hours and 1 week). Results Fifty patients were identiied between January and April 2009. There was an age range of 24 to 86 (mean = 62). The commonest cause for referral was respiratory failure (40%). Overwhelming sepsis requiring inotropic and ICU support was also common (28%). Patients were most frequently deemed unsuitable for admission as they were too well at the time of referral (48%). The second most common reason for unsuitability was co-morbidities (32%) with nine (18%) identiied as sufering probable fatal insults. One patient was referred for assessment for ICU support post emergency surgery which was not required. A number of patients remained in hospital at 1 week post referral, with ongoing illness (32%) or rehabilitation (8%). Twenty-six per cent (13/50) of patients were discharged home and 34% (17/50) died. Of those that died, 59% were within 24 hours of ICU referral. All other deaths occurred within 1 week of referral. Nine Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 of these 17 had been identiied as having nonsurvivable insults at ICU referral, seven as having excess co-morbidities making ICU inappropriate, and just one identiied as being too well. Conclusions This study suggests that our ICU team is both sensitive and speciic at identifying those patients who are either too well for admission or those patients for whom ICU is unlikely to be of beneit as their insult is presumed fatal. We suggest those patients whom the ICU identiies as unlikely to survive should be assessed and referred to the palliative care team, where appropriate. This should facilitate appropriate communication of this by clinical staf and allow the relevant social, psychological and spiritual preparations for death that are the hallmarks of good care of the dying. References 1. 2. 3. 4. 5. 6. [http://www.sicsag.scot.nhs.uk] Joynt G, et al.: Intensive Care Med 2001, 27:1459-1465. Lyons RA, et al.: Lancet 2000, 355:595-598. Thiery G, et al.: J Clin Oncol 2005, 23:4406-4412. Crippen D: Crit Care Med 2009, 37:1498-1499. Wood G, et al.: Crit Care Med 2009, 37:1147-1148. P416 Admission pattern and outcome in a UK weaning centre S Goodhand, K Stewart, L McGee, N Grey, A Williams, C Davidson, N Hart Guy’s and St Thomas’ Foundation Trust, London, UK Critical Care 2010, 14(Suppl 1):P416 (doi: 10.1186/cc8648) Introduction Although patients with weaning failure may be transferred to weaning centres, there are limited data on admission practice and clinical outcome. Methods We collected data prospectively from March 2005 to October 2009. Results There were 286 referrals of which 20% were not accepted for transfer. Patients that were not accepted were categorised as weanable locally, unweanable, or died prior to transfer. A total 172/229 accepted patients were admitted (mean age was 60 ± 17 years; 118 male). Forty-six per cent of these achieved ventilator independence with 21% requiring ongoing non-invasive ventilation (NIV). The median time to wean was 17 days with 16% of patients remaining tracheostomy ventilator dependent. The unit mortality was 17%. Neuromuscular disease (NMD) was the main referral group (36%) with a low mortality rate (6%). COPD and postsurgical patients both comprised 21% of the referrals and had respective mortalities of 37% and 25%. There were no in-hospital deaths in the obesity-related respiratory failure (ORRF) group, but this was the smallest referral group (3%). Of 57 patients declined transfer, 43 (83%) were assessed as unweanable and nine (17%) were assessed as weanable locally. Of 56 patients accepted but not transferred, 28 (50%) were weaned awaiting transfer and 23 (41%) died prior to transfer. Mean transfer delay was 20.3 ± 19.2 days and a major contributor to this delay was prolonged discharge delay following weaning (12.9 ± 19.3 days) and extended discharge delay of tracheostomy-ventilated patients (77.4 ± 51.8 days). Conclusions In conclusion, compared with our previous data [1], there was an absolute reduction in mortality of 10% with similar admission diagnoses, proportions achieving ventilator independence and requiring NIV, suggesting that this was not necessarily selection bias. NMD was the main referral group with a low mortality rate. Although COPD patients had the highest mortality, almost 50% were weaned from invasive ventilation. There were no in-hospital deaths in the ORRF group, but these patients had the longest weaning time. In addition, poor outcome was observed in patients accepted but not transferred due to delay. This study highlights the need for more speciality weaning facilities in the UK. Reference 1. Thorax 2005, 60:187-192. P417 Referral to intensive care: who and when? A Mackay, J Erskine, P Doherty, E McMillan Victoria Inirmary, Glasgow, UK Critical Care 2010, 14(Suppl 1):P417 (doi: 10.1186/cc8649) Introduction Intensive care beds in the UK are a limited resource and deciding whether or not to admit a patient to intensive care is often a S140 diicult decision. It is increasingly felt that, as intensive care consultants are involved in the decision-making process for every admission, the consultant from the referring team should also be involved in the referral process. The Scottish Intensive Care Society Trainee Group found that this occurred in less than 50% of occasions during the Referral and Review Audit of 2007 [1]. We wished to establish what the referral process was like in our hospital. Methods We undertook a prospective audit of all referrals to a ive-bed teaching hospital ICU between April and July 2009. Data were collected regarding time of referral, seniority of referrer, involvement of referring consultant, seniority of ICU trainee, involvement of ICU consultant and whether or not the referral resulted in intensive care admission. Results Ninety-eight referrals were received during the audit period. Of 31 medical referrals, 21 were out of hours, 16 had no consultant involvement and ultimately 27 patients were admitted. Of nine surgical patients, three were out of hours, three had no consultant involvement and seven were eventually admitted. Thirty patients were referred by the emergency department, of whom 18 were out of hours, 23 had no consultant involvement and 26 resulted in admission. Twenty-eight patients were referred by anaesthetics, all of whom had been seen by a consultant and were admitted. Conclusions General medicine is the most signiicant contributor to outof-hours work of the intensive care medical staf. Over 50% of medical referrals have no referring consultant involvement, although ultimately many of these patients are admitted and are seen by an intensive care consultant within a few hours of admission. Most surgical patients are admitted postoperatively and thus are referred by a consultant anaesthetist, resulting in a very high conversion rate for referrals to admissions. Emergency medicine is increasingly a consultant delivered service with increased presence in the department into the extended working day, a fact that is sadly not relected in our results. It is regrettable that despite repeated recommendations that intensive care admission should be on the basis of consultant to consultant referral, 43% of patients are referred to intensive care without any referring consultant involvement. Reference 1. Scottish Intensive Care Society Annual Report 2008 [http://www. scottishintensivecare.org.uk/sics/Annual%20Report/2008%20annual%20 report.pdf ] P418 Acute drug overdose in an ICU: 15 years experience L Cachafeiro, JJ Manzanares, S Yus, C Soriano, M Oliveros, M Jimenez Hospital Universitario La Paz, Madrid, Spain Critical Care 2010, 14(Suppl 1):P418 (doi: 10.1186/cc8650) Introduction The aim of our study is to identify the epidemiology of patients admitted to an ICU following severe acute drug overdose. Methods The study is a retrospective observational study of a 20-bed medical/surgical ICU during a 15-year period. We reviewed the clinical records of patients admitted from 1994 to 2008 with acute drug overdose. Data on demographics, mean length of stay, days on mechanical ventilation (MV), Glasgow Coma Scale (GCS) on admission, and mortality were recorded. The type of drug was also stated. Results A total of 12,881 patients were admitted to our ICU from 1994 to 2008, of them 621 patients (4.8%) had a diagnosis of acute intoxication on admission. From these 621 patients, 159 (25.6%) were drug overdoses, which represented 1.2% from the total admissions. The median age was 33 years, the range 15 to 87, with a standard deviation of 12.5. A total of 50.9% were male. The median GCS on admission was 6 and the APACHE II score was 16, with a range 3 to 31 and a standard deviation of 6.7. MV was required by 71.1% with a median duration of 2.38 days, with a range 0 to 45 and a standard deviation of 6.9. The median length of stay was 3.2 days, the range 0 to 41 and a standard deviation of 6.1. The types of drugs found were ethanol, cocaine, opioids (methadone, heroin, opium), LSD, ketamine, GHB, amphetamines, cannabis, and PCP. Ethanol was the most commonly encountered in 57%, followed by cocaine in 37%, and opioids in 27% of patients. Global mortality was 2%, and 50% of these were due to ethanol. Conclusions In our study, severe acute drug overdose accounts for a low percentage of patients admitted to the ICU. The proile is that of a middleaged male patient with acute ethanol, cocaine, or opioids overdose, in Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 that order of frequency, and with rates similar to those of national and European statistics, of short length of stay (3.2 days) and a mortality inferior to that expected for the APACHE II score. References 1. 2. Palazon Sanchez C, et al.: Rev Esp Salud Publica 2000, 74:55-63. Caballero Valles PJ, et al.: An Med Interna 2008, 25:262-268. P419 Prognostic factors for very short-term mortality in severe sepsis E Silva1, R Salomao2, O Rigato3, E Ferreira2, T Mohovic1, S Callas3, N Tereran2, M Assuncao1, N Delbiagi3, F Colombari1, C Silva4, R Cal4, F Machado2 1 Hospital Israelita Albert Einstein, São Paulo, Brazil; 2Federal University of São Paulo, Brazil; 3Hospital Sirio-Libanes, São Paulo, Brazil; 4Latin American Sepsis Institute, São Paulo, Brazil Critical Care 2010, 14(Suppl 1):P419 (doi: 10.1186/cc8651) Introduction Short-term mortality studies could be crucial for evaluating new therapies as well as to better understand pathophysiological aspects. This study aims to identify prognostic factors associated with sepsisrelated death within 4 days after the irst organ dysfunction development. Methods All severe sepsis and septic shock patients over 18 years old admitted to three Brazilian ICUs were prospectively included. Demographic, clinical and outcome features, including compliance to the 6-hour Surviving Sepsis Campaign bundle (SSC-6h), were collected in an electronic clinical research form. Duration of organ dysfunction was deined as the time elapsed between the installation of the dysfunction and its diagnosis by the healthcare provider. Results were expressed as a percentage or as median and interquartiles. Univariate analysis was performed by chi-squared or Student t test. P <0.05 was considered signiicant. Results Three hundred and eighty-six patients were included, being 30 (7.8%) in Group 1 (short-term mortality group, median time from organ dysfunction to death: 2.39 (1.75 to 3.25) days) and 356 (92.2%) in Group 2. No diference was found between the groups regarding gender (P = 0.14), age (P = 0.80), being in a public hospital (P = 0.94) or duration of organ dysfunction (P = 0.79). Variables related to severity of disease were associated with early mortality: APACHE II score (Group 1: 21.0 (15.0 to 26.0), Group 2: 18.0 (14.0 to 22.0), P = 0.01); SOFA score at admission (SOFA0) (Group 1: 9.0 (8.0 to 11.0), Group 2: 7.0 (5.0 to 9.0), P = 0.003); Day 1 SOFA score (10.0 (8.0 to 12.0), Group 2: 7.0 (5.0 to 10.0), P = 0.0002); Day 3 SOFA score (SOFA3) (Group 1: 9.0 (8.0 to 12.0), Group 2: 7.0 (4.0 to 10.0), P = 0.006) and the delta between SOFA0 and SOFA3 (Group 1: –6.5 (–11.0 to +1.0), Group 2: –1.0 (–3.0 to +9.0), P = 0.003). Delta SOFA with Day 1 was not diferent between groups. Group 1 patients had a trend towards higher number of organ dysfunction (P = 0.07) and more septic shock episodes (P = 0.09). Regarding treatment adequacy, compliance with any indicator or the entire SSC-6h bundle was not related to survival. However, achievement of the CPV target was associated with a higher early mortality (Group 1: 69.6%, Group 2: 40.6%, P = 0.013; OR – 3.3.4 (1.33 to 8.40)). Conclusions In this observational study, factors related to disease severity rather than to the evidence-based treatment compliance were associated with short-term death among severe septic patients. P420 Is sepsis mortality rate driven by diferences in Brazilian healthcare systems? F Machado1, R Salomao1, O Rigato2, E Ferreira1, T Mohovic3, G Schettino2, N Tereran1, M Assunçao3, R Caltabiano2, F Colombari3, C Silva4, R Cal3, E Silva3 1 Federal University of São Paulo, Brazil; 2Hospital Sirio-Libanes, São Paulo, Brazil; 3Hospital Israelita Albert Einstein, São Paulo, Brazil; 4Latin American Sepsis Institute, São Paulo, Brazil Critical Care 2010, 14(Suppl 1):P420 (doi: 10.1186/cc8652) Introduction The sepsis mortality rate is higher in Brazilian public hospitals with no clear diferences in risk factors. We aim to identify risk factors that could explain why the mortality rate is diferent in public and private hospitals. S141 Methods All severe sepsis and septic shock patients over 18 years old admitted to two private ICUs (Group 1) and one public ICU (Group 2) were prospectively included. Demographic, clinical and outcome features, including compliance to the 6-hour Surviving Sepsis Campaign bundle (SSC-6h), were collected in an electronic CRF. Duration of organ dysfunction was deined as the time elapsed between the installation of the dysfunction and its diagnosis by the healthcare provider. Results were expressed as a percentage or as median and interquartiles, and P <0.05 was considered signiicant. Results Three hundred and eighty-six patients were included (Group 1 – 210, Group 2 – 176). Patients from Group 1 were older (69.5 (53.0 to 81.0) years vs 59.0 (43.5 to 73.5) years, P <0.000), had a higher APACHE II score (19.0 (15.0 to 23.0) vs 17.0 (13.0 to 23.0), P = 0.01), had more organ dysfunctions (3.0 (2.0 to 4.0) vs 2.0 (2.0 to 4.00), P = 0.08), and more septic shock episodes (74.3% vs 60.8%, P = 0.006). No diference was found regarding gender, site of infection, and day 1 or day 3 delta SOFA score. However, the mortality rate was higher in Group 2 than in Group 1, 60.8 and 38.3, respectively. Compliance to the SSC-6h bundle did not explain this diference as they were better in Group 2 for lactate (70.5% vs 49.8%), blood culture (61.4% vs 52.4%), achieving MAP >65 mmHg (98.8% vs 90.5%), and completion of the bundle (15.9% vs 4.8%). Only antibiotics (63.3% vs 54.5%, P = 0.10) and CVP had a better performance in Group 1 (49.4% vs 33.3%, P = 0.01). SOFA score at admission was slightly higher on Group 2 (7.0 (4.0 to 9.0) vs 8.0 (5.5 to 10.0), P = 0.004). However, duration of organ dysfunction was clearly longer in Group 2 (150.0 (0.0 to 650) minutes vs 360.0 (0.0 to 1008.0) minutes, P = 0.02). In all patients, we have identiied some variables associated with mortality, including being in the public hospital (OR 2.46 (1.63 to 3.72), P = 0.00002), as well as the median duration of organ dysfunction, SOFA at admission, age, APACHE II score and number of organ dysfunctions. Conclusions The mortality rate was higher in the public hospital despite better SSC bundle adherence. A delay in initiating those interventions may negatively impact the outcome in patients treated in public hospital. P421 Prognoses indicators of HIV patients admitted to the ICU B Moya, N Germano, G Imelda Hospital de S. Bernardo, Setúbal, Portugal Critical Care 2010, 14(Suppl 1):P421 (doi: 10.1186/cc8653) Introduction The level of immunity in HIV patients is associated with a high mortality, particularly when CD4+ lymphocytes are inferior to 200 cells/mm3. Besides the immunity, other prognoses indicators are necessary. Methods The author performed a revision of 1,028 admissions to the ICU from January 2007 and November 2009. Selected were the cases of HIV patients with low immunity (L CD4+ <200 cells/mm3). The following parameters were collected at admission to the ICU: viral load, LDH, albumin, hemoglobin, Hct, thrombocytopenia, presence of opportunistic infection, nutritional status, need for mechanical ventilation, renal insuiciency and history of antiretroviral therapy (ART). Demographic parameters were also collected. The primary endpoint was mortality, secondary endpoints were ICU length stay and days of mechanical ventilation. Results Fifteen patients were selected; all of them were medical admissions mainly from the emergency department. Sixty-ive percent had previous history of opportunistic infection, and only two patients had ART. The main reason to suspend ART was social and drug-dependency problems. Sepsis was diagnosed in 73% of the patients. Pneumocystis carinii pneumonia was diagnosed in 80% of the patients. Fungus infection was diagnosed in 60% of patients. One patient had pulmonary tuberculosis and another had Leishmania infection. The mortality rate was 53%. The factors associated with high mortality were: P. carinii pneumonia, malnutrition and absence of ART. Conclusions The patient’s nutritional status is an independent predictor of mortality in HIV patients. References 1. 2. Johannessen A, Naman E, et al.: Predictors of mortality in HIV-infected patients starting antiretroviral therapy in a rural hospital in Tanzania. BMC Infect Dis 2008, 8:52. Swaminathan S, Padmapriyadarsini C, et al.: Nutritional status of persons with HIV infection, persons with HIV infection and tuberculosis, and HIVnegative individuals from southern India. Clin Infect Dis 2008, 46:946-949. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P422 Outcomes of cancer patients admitted to intensive care units with severe acute kidney injury S Lobo, M Soares, A Torelly, P Mello, U Silva, J Teles, E Silva, P Caruso, G Friedman, P Souza, A Rea-Neto, A Vianna, M Maia, J Salluh Brazilian Research in Intensive Care Network – BRICNet, Rio de Janeiro, Brazil Critical Care 2010, 14(Suppl 1):P422 (doi: 10.1186/cc8654) Introduction Critically ill cancer patients are at increased risk for acute kidney injury (AKI), but studies on these patients are scarce and were all single centered, conducted in specialized ICUs. The aim of this study was to evaluate the characteristics and outcomes in a prospective cohort of ICU cancer patients with AKI. Methods Prospective multicenter cohort study conducted in ICUs from 28 hospitals in Brazil over a 2-month period. Univariate and multivariate logistic regression were used to identify factors associated with hospital mortality. Results Out of all 717 ICU admissions, 87 (12%) had AKI and 36% of them received dialysis. Kidney injury developed more frequently in patients with hematological malignancies than in patients with solid tumors (26% vs 11%, P = 0.003). Ischemia/shock (76%) and sepsis (67%) were the main contributing factors, and kidney injury was multifactorial in 79% of the patients. The ICU mortality was 61% (53/87) and hospital mortality was 71% (62/87). Despite the lack of statistical signiicance, hospital mortality was higher in patients who received RRT later on during the ICU stay (92%) in comparison with those who received RRT on the irst day in the ICU (78%) and those who were not dialyzed (64%) (P = 0.105). End-of-life decisions (to withhold or to withstand therapies) were taken in 18 (23%) patients. General and renal-speciic severity-of-illness scores were inaccurate in predicting outcomes for these patients. In a multivariate analysis, length of hospital stay prior to ICU, acute organ dysfunctions, need for mechanical ventilation and a poor performance status were associated with increased mortality. Moreover, cancer-related characteristics were not associated with outcomes. Conclusions The present multicenter study conirmed that AKI in critically ill patients with cancer is frequent, usually multifactorial and still associated with high mortality rates. On the other hand, the current study also suggests that ICU admission and RRT should be considered in selected patients. Mortality in these patients is mostly dependent on the severity of acute illness and the performance status, rather than cancerrelated characteristics. S142 multivariate analysis identiied three variables independently associated with ICU survival: two negative, mechanical ventilation (HR = 4.9) and LODS score (HR = 1.12); one protective factor, red blood cell transfusion (HR = 0.7) without additional cost. ICU, 3-month, 12-month and 18-month survivals were respectively 69.3% (61/88), 37.5% (33/88), 27.3% (24/88) and 23.8% (21/88) with a mean performance status at 1.03 ± 1, a mean Karnofsky index at 77.6 ± 15. Conclusions The ICU management provided beneit for PHM cases referred earlier to the ICU because of the good quality of life for long-term survivors. Therefore, the unlimited life-sustaining treatment should be re-evaluated on the irst 48 hours in the ICU based on SAPS II, LODS and Charlson scores. P424 Postoperative mortality in the Netherlands: identifying high-risk surgery PG Noordzij OLVG, Amsterdam, the Netherlands Critical Care 2010, 14(Suppl 1):P424 (doi: 10.1186/cc8656) Introduction Type of surgery is considered a risk factor of adverse outcome, but mortality rates of common procedures are scarce [1,2]. The objective of the study was to further identify high-risk patients by procedure-speciic mortality. Methods Data between 1991 and 2006 were obtained from Dutch national healthcare statistics. Patients age >20, with an elective, nonday case, open surgical procedure were enrolled. Data included main diagnosis, secondary diagnoses, dates of admission and discharge, death during admission, operations, age, gender, and co-morbidities according to ICD-9-CM. Logistic regression analyses were applied to evaluate the relationship between type of surgery and postoperative mortality. P423 Is intensive care beneicial for patients with haematologic malignancies? M Nyunga, C Lemaire, E Ras, P Herbecq, I Verheyde Centre Hospitalier de Roubaix, France Critical Care 2010, 14(Suppl 1):P423 (doi: 10.1186/cc8655) Introduction Despite a better prognosis for patients with haematologic malignancies (PHM) over these past years due to progress in management, intensivists are reluctant to admit those patients to the ICU because of high mortality rates, above 50%. The aim of this study was to retrospectively evaluate the value of intensive care therapy of PHM and predictive factors of short-term and long-term survival with the best post-ICU quality of life. Methods The case notes of 88 PHM patients requiring admission to a 25bed medical–surgical ICU of Roubaix Hospital, France were retrospectively reviewed during a 5-year period, 2003 to 2007. We collected demographic factors, Simpliied Acute Physiology Score II (SAPS II), Logistic Organ Dysfunction System score (LODS), Charlson score, microbiology, status of underlying HM, haematologic factor data, therapeutic support, blood cell transfusion, and survival follow-up (at the irst 48 hours on the ICU, at discharge from the ICU, at 3, 12 and 18 months after ICU). Results Univariate logistic regression analysis of factors previously shown to inluence survival revealed that HM status, Charlson score, PaO2/FiO2 <200, during mechanical ventilation, blood cell transfusion, and outcome in the irst 48 hours on the ICU were signiicantly associated with survival (P <0.05). PHM with a favourable course (treatment response) in the irst 48 hours on the ICU had a better survival rate (95.7%) than an unfavourable course (33.3%) (P <0.001). There was a correlation between mean SAPS II, LODS and outcome at the irst 48 hours on the ICU (P = 0.03). Using Figure 1 (abstract P424). Absolute incidence of postoperative mortality in relation to type of procedure. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Results A total of 3,667,875 surgical procedures, from 102 hospitals, were included. Postoperative death was observed in 67,879 patients (1.85%). Overall, vascular surgery had highest mortality (incidence 6.0%). Abdominal surgery was associated with 2% mortality. However, procedure-speciic adjusted mortality identiied spleen (adjusted OR 6.84), liver (adjusted OR 5.45), gastric (adjusted OR 4.86) and pancreatic surgery (adjusted OR 4.38) as higher risk procedures than aortic surgery (adjusted OR 2.5) (Figure 1). Conclusions This study revealed a procedure-speciic risk classiication to accurately identify high-risk patients. References 1. 2. Lee TH, et al.: Circulation 1999, 100:1043-1049. Fleisher LA: J Am Coll Cardiol 2007, 50:1707-1732. P425 Outcomes of 1,000 patients with cancer admitted to the intensive care unit: a Brazilian prospective study F Galas1, L Hajjar2, J Almeida1, T Trielli1, S Vieira1, M Bazan1, H Palomba1, C Simoes1, V Torres1, R Kalil-Filho1, P Hof1, J Auler Jr1 1 Instituto do Cancer do Estado de São Paulo, Brazil; 2Heart Institute, São Paulo, Brazil Critical Care 2010, 14(Suppl 1):P425 (doi: 10.1186/cc8657) Introduction ICU admission of critically ill cancer patients was controversial until recently. In the past years, advances in the management of malignancies and organ failures have improved outcomes of patients, resulting in higher rates of survival in the ICU. The aim of this study is to prospectively evaluate the characteristics, short-term and mid-term outcomes of cancer patients requiring intensive care. Methods During 1 year, we evaluated prospectively patients with cancer admitted to the Instituto do Cancer do Estado de São Paulo. A total of 1,000 patients were included in the study; and collected data were: baseline data, risk scores, clinical status, co-morbidities, admission diagnosis, ICU interventions, ICU and hospital outcomes and 90-day outcomes. Results From 1,000 patients, 828 (82.8%) had solid tumors and 172 (17.2%) had hematologic malignancies. The most frequent reasons for ICU admission were: sepsis (31%), postoperative care (29%) and respiratory failure (24%). The mean APACHE II score value at the day of admission was 24.1 ± 8.8 (8 to 45). ICU mortality was 24%, hospital mortality was 32% and 3-month mortality was 41%. Logistic regression analysis showed that need for mechanical ventilation (odds ratio = 6.76; 95% CI = 3.56 to 12.85), presence of metastasis (odds ratio = 3.87; 95% CI = 2.06 to 7.28), occurrence of acute renal failure (odds ratio = 3.92; 95% CI = 1.47 to 10.46) and higher SOFA scores 72 hours after admission (odds ratio = 5.76; 95% CI= 4.56 to 14.85) were independently associated with increased hospital mortality. Three-month quality of life of patients who survived was considered unchanged in 55% patients, worse in 25% and better in 20%. Conclusions This prospective analysis of 1,000 patients with cancer needing intensive care shows high survival rates and good quality of life after ICU admission. These data encourage intensive care treatment in oncologic patients to prevent, detect and cure organ dysfunction. References 1. 2. Azoulay E, Thiery G, Chevret S, et al.: The prognosis of acute respiratory failure in critically ill cancer patients. Medicine 2004, 83:360-370. Soares M, Salluh JI, Torres VB, et al.: Short- and long-term outcomes of critically ill patients with cancer and prolonged ICU length of stay. Chest 2008, 134:520-526. P426 Trend in outcome of critically ill patients with co-morbidity: a 15-year study B Afessa, O Gajic, MT Keegan Mayo Clinic, Rochester, MN, USA Critical Care 2010, 14(Suppl 1):P426 (doi: 10.1186/cc8658) Introduction Critically ill patients with underlying co-morbidity have a high hospital mortality rate. This study describes the trend in the severityadjusted mortality of such patients over a 15-year period. Methods We used the Acute Physiology and Chronic Health Evaluation (APACHE) III database of our institution to identify patients with solid S143 tumors, hematology malignancy, and hepatic cirrhosis. We categorized the 15-year study period into three 5-year groups. We calculated the standardized mortality ratio (SMR) with the 95% conidence interval (CI) for each co-morbidity. Results During the study period, there were 73,626 ICU admissions; 92.6% white, 56.1% male, mean age 62.7 years, and 17.7% with comorbidities. The overall mortality rate of the study population was 10.2%: 7% for patients with no co-morbidity, 21.1% for solid tumors, 25.7% for hematology malignancy, and 29.2% for hepatic cirrhosis. The predicted mortality rates were 9.9% for patients with no co-morbidity, 25.6% for solid tumors, 27.6% for hematology malignancy, and 35.7% for hepatic cirrhosis. The SMR (95%) CI for patients without co-morbidity was 0.71 (0.66 to 0.75), 0.83 (0.79 to 0.87), and 0.62 (0.59 to 0.65) for the irst, second, and third 5-year periods, respectively. The SMR (95%) CI for the each co-morbidity is presented in Table 1. Table 1 (abstract P426). SMR, 95% CI for each co-morbidity Co-morbidity First 5-year Second 5-year Third 5-year Hematology 1.16, 1.03 to 1.30 0.95, 0.88 to 1.02 0.85, 0.79 to 0.91 Cirrhosis 1.12, 0.95 to 1.31 0.82, 0.73 to 0.92 0.70, 0.62 to 0.80 Solid tumor 0.80, 0.68 to 0.93 0.84, 0.75 to 0.93 0.82, 0.74 to 0.91 Conclusions The severity-adjusted hospital mortality of critically ill patients with hematology malignancy and hepatic cirrhosis has improved over the past 15 years. P427 Clinical proile, maternal and fetal mortality analysis of severe gestosis admitted to the ICU E Curiel Balsera, M Prieto Palomino, G Quesada Garcia, J Muñoz Bono, J Mora Ordoñez, MJ Ruiz de Elvira Carlos Haya Hospital, Málaga, Spain Critical Care 2010, 14(Suppl 1):P427 (doi: 10.1186/cc8659) Introduction Pre-eclampsia is a severe multisystemic disease that may occur in pregnancy or in the immediate postpartum period. Methods We included prospectively women admitted to the ICU with the diagnosis of severe gestosis, from January 1998 to October 2007. We deine pre-eclampsia, eclampsia and HELLP syndrome as used by the American College of Obstetrics and Gynecology. Qualitative variables are shown as a percentage and quantitative variables as mean ± standard deviation or median and interquartile range. We used the chi-square test, t test and multivariate testing for statistical analysis of the data. Results We report data from 262 women. Median age was 31 years (27 to 34). The admission diagnosis was pre-eclampsia 77.48%, eclampsia 6.11% and HELLP syndrome 16.41%. Complications registered were pulmonary oedema 9%, coagulopathy 2% and renal failure 5%. Delivery was by cesarean in 89.69%. The median newborn weight was 1,500 mg (1,000 to 2,140). We did not ind signiicant diference on systolic pressure between preeclampsia, eclampsia or HELLP nor in uric acid levels. Gestational age was signiicantly lower in pre-eclampsia than in eclampsia or HELLP (P <0.0001) and, additionally, the weights of the newborn were signiicantly lower in pre-eclampsia versus eclampsia and HELLP. Maternal mortality was 1.5% and fetal mortality 16.3%. Maternal death is associated with complications in the ICU (renal failure, heart failure or coagulopathy) (P <0.034), OR 6.55 (95% CI 0.89 to 48.12), but multivariate analysis shows only coagulopathy as an independent mortality risk factor (P <0.026), OR 30.3 (95% CI 1.5 to 609.8). Fetal mortality is associated in multivariate analysis with newborn weight <1 kg (P = 0.026), OR 4.1 (95% CI 1.1 to 14.3), and higher gestational age at delivery is protective (P = 0.001), OR 0.68 (95% CI 0.54 to 0.85). Conclusions Women admitted to the ICU are mostly 31 years old, in the 32-week gestational age of their irst pregnancy. In our environment, delivery mostly occurs in the following 5 to 7 days of admission. Maternal mortality is low, but not so fetal mortality that rises up to 16,3%. Maternal mortality is associated with complications such as coagulopathy, and fetal mortality mostly with gestational age and low birth weight. Reference 1. Sibai BM: Diagnosis and management of gestational hypertension and preeclampsia. Obstet Gynecol 2003, 102:181-192. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P428 Obstetric critical care in developing countries: a comparison between two intensive care units JA Rojas-Suárez1, FP Paruk2, JE Miranda-Quintero1, AP Paternina-Caicedo 1, OD De la Ossa-Mercado3 1 Universidad de Cartagena, Cartagena de Indias, Colombia; 2University of Witwatersrand, Johannesburg, South Africa; 3GRICIO, Cartagena de Indias, Colombia Critical Care 2010, 14(Suppl 1):P428 (doi: 10.1186/cc8660) Introduction To describe both characteristics and diferences of critically ill obstetric patients in two ICUs from two developing countries. Methods A comparative study between two historic cohorts (2001 to 2002 from South Africa and 2006 to 2007 from Colombia) was designed to analyze characteristics from two ICUs in two developing countries: one in South Africa, King Edward VII Hospital (KEH) (South Africa); and another in Colombia, Clínica Maternidad Rafael Calvo (CMRC) (Colombia). Diferences between both cohorts were assessed through chi-square and ANOVA. P <0.05 was considered statistically signiicant. Results There was a high rate of obstetrical admissions in both ICUs. Three hundred and ninety-eight patients were registered during these periods of time: 214 patients were from South Africa, 184 from Colombia. The most frequent diagnosis was hypertensive disorders during pregnancy (KEH = 65.4%, CMRC = 47%; P <0.001). There were no statistical diferences between the two ICUs regarding age, gestational age, ICU stay/days and mechanical ventilation days. There were statistically signiicant diferences in APACHE II score and mortality, being highest in South Africa. All types of organ dysfunctions were lower in CMRC; with statistical signiicance in cardiovascular, haematologic and neurologic dysfunction. OR from mechanical ventilation was 0.02 (P <0.001), being lower in CMRC (25.67%). There were no statistical diferences in cesarean section and haemodialysis. Conclusions Obstetric critical care is considered of special interest in these countries, where 90% of global maternal mortality can be found. Although there are common characteristics regarding admissions of these patients to ICU settings, it is also evident that diferences are noted when considering demographics and interventions in obstetric critically ill patients. References 1. 2. 3. Soubra SH, Guntupalli KK: Critical illness in pregnancy: an overview. Crit Care Med 2005, 33:S248-S255. Martin S, Foley M: Intensive care in obstetric: an evidence-based review. Am J Obstet Gynecol 2006, 195:673-689. Zeeman G: Obstetric critical care: a blueprint for improved outcomes. Crit Care Med 2006, 34:S208-S214. P429 Co-morbidity, demographic and social factors as predictors of outcome from intensive care: an observational cohort study A Mackay, R Docking, J Kinsella, M Booth Glasgow Royal Inirmary, Glasgow, UK Critical Care 2010, 14(Suppl 1):P429 (doi: 10.1186/cc8661) Introduction Critically ill patients arrive in intensive care with various degrees of impairment in chronic health. These are recognised to have an impact upon survival and the Acute Physiology and Chronic Health Evaluation II (APACHE II) system utilises this when predicting mortality. We wished to look at the impact of many of these factors upon outcome from our intensive care. Methods A prospective case-note review of 500 consecutive admissions to Glasgow Royal Inirmary ICU was undertaken over an 18-month period. Details of co-morbidity, social factors, regular medication and exercise tolerance were sought from the patients’ case notes by hand using details of current and previous admissions, clinic letters, results of investigations and correspondence from the patient’s general practitioner, using agreed criteria. Demographic, APACHE II score and outcome data were retrieved from the Ward Watcher system in the ICU. Data were analysed using a univariate analysis model and chi-square test. Results Complete data were available for 500 patients. Population demographics were as follows – 65% male, mean age 53.8 ± 4.1 years, median APACHE II score 18 (IQR 12 to 24), crude ICU mortality 33.6%. The following factors were associated with an increased mortality (odds S144 ratio, P value): age >50 years (OR 3.11, P <0.001), cigarette smoking (OR 1.57, P = 0.02), NYHA class 3/4 (OR 2.52, P <0.001), ischaemic heart disease (OR 1.70, P = 0.01), peripheral vascular disease (OR 1.91, P = 0.04), chronic obstructive pulmonary disease (OR 2.56, P <0.001), alcoholic liver disease (OR 3.86, P <0.001). The following factors were not signiicantly associated with increased mortality: male gender, social deprivation, unemployment, alcohol excess, intravenous drug use, polypharmacy, hypertension, diabetes, obesity or concurrent malignancy. Conclusions These results suggest signiicant increased ICU mortality in the following groups: over 50 years old, smokers, patients with poor exercise tolerance, patients with IHD or PV, patients with COPD and patients who drink alcohol to excess or those with ALD. While these results should not be used as a basis upon which to permit or refuse intensive care admission, they should be used to inform staf and patients of likely outcome from intensive care. P430 C-Reactive protein and albumin as prognostic markers in intensive care A Mackay, J Erskine, O Kerr, L Marshall, A Davidson Victoria Inirmary, Glasgow, UK Critical Care 2010, 14(Suppl 1):P430 (doi: 10.1186/cc8662) Introduction C-reactive protein (CRP) is an acute-phase protein, the blood levels of which increase rapidly in response to infection, trauma, ischemia, burns, and other inlammatory conditions. Serum albumin decreases in critically ill patients with similar conditions. The use of these blood tests as risk markers or as predictors of organ failure and death has been studied previously [1,2] and we wished to investigate their applicability to our population. Methods A retrospective laboratory result review of 300 consecutive admissions to the Victoria Inirmary ICU was undertaken. Demographic, APACHE II score and outcome data were retrieved from the Ward Watcher system in the ICU. We compared survivors’ and nonsurvivors’ levels of CRP and albumin on day of admission and looked at correlation with length of stay and duration of mechanical ventilation. Data were analysed using Student’s t test and the Pearson correlation coeicient where appropriate. Results Complete data were available for 287 patients. Population demographics were as follows – 61% male, mean age 56.4 ± 2.0 years, median APACHE II score 20 (IQR 15 to 27), crude ICU mortality 24.7%. Comparing survivors and nonsurvivors, admission CRP was signiicantly higher in nonsurvivors (144.7 vs 113.0, P = 0.037) whereas admission albumin was signiicantly lower in nonsurvivors (21.3 vs 24.7, P = 0.003). Admission CRP correlated positively with length of stay (r = 0.14, P = 0.017) and APACHE II score (r = 0.13, P = 0.03) but did not signiicantly correlate with duration of mechanical ventilation (r = 0.10, P = 0.103). Admission albumin correlated negatively with length of stay (r = –0.15, P = 0.01), duration of mechanical ventilation (r = –0.15, P = 0.014) and APACHE II score (r = –0.17, P = 0.004). Conclusions CRP and serum albumin on admission are both predictors of intensive care mortality. CRP and serum albumin also correlate signiicantly with other severity markers such as length of stay and duration of mechanical ventilation and also APACHE II score. References 1. 2. Lobo SMA, et al.: C-Reactive protein levels correlate with mortality and organ failure in critically ill patients. Chest 2003, 123:2043-2049. FHY Yap et al.: Association of serum albumin concentration and mortality risk in critically ill patients. Anaesth Intensive Care 2002, 30:202-208. P431 Statin therapy on admission to intensive care and outcome: an observational cohort study A Mackay, R Docking, J Kinsella, M Booth Glasgow Royal Inirmary, Glasgow, UK Critical Care 2010, 14(Suppl 1):P431 (doi: 10.1186/cc8663) Introduction Statins are powerful hypolipaemic drugs that are proven to improve survival in patients with atherosclerosis. Their efects are not limited to lowering cholesterol but also include anti-inlammatory and antioxidative properties. For these reasons, it has been postulated Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 that statins may reduce mortality in critically ill patients. We aimed to investigate the association between statin therapy on admission and outcome from intensive care in our ICU. Methods A prospective case-note review of 504 consecutive admissions to Glasgow Royal Inirmary ICU was undertaken over an 18-month period. Details of statin prescription, cardiovascular co-morbidity and smoking status was sought from the patients’ case notes by hand using details of current and previous admissions, clinical letters, results of investigations and correspondence from the patient’s general practitioner, using agreed criteria. Demographic, Acute Physiology and Chronic Health Evaluation II (APACHE II) score and outcome data were retrieved from the Ward Watcher system in the ICU. Results Complete data were available for 444 patients. One hundred and eleven (25%) of these were on statin therapy on admission to intensive care. All data are expressed as mean ± 95% conidence interval or median (interquartile range). Diferences between groups were tested using the chi-squared test, Mann–Whitney test and unpaired Student’s t test. Compared with patients without concurrent statin therapy, patients on statin therapy are more likely to be male (76.6% vs 63%, P = 0.009), older (65.2 ± 1.93 years vs 49.7 ± 1.86 years, P <0.001), have a higher APACHE II score (20 (15 to 25) vs 16 (11 to 23), P <0.001), have ischaemic heart disease (69.4% vs 17.1%, P <0.001), and have hypertension (47.5% vs 0.22%, P <0.001). There was no signiicant diference in mortality in the ICU (27.9% vs 27%, P = 0.86) or the hospital (40.5% vs 31.2%, P = 0.07). Conclusions Statin therapy does not signiicantly alter ICU or hospital mortality in our population. There are signiicant diferences in APACHE II scores between the groups and predicted mortality which may suggest that patients on statins fare better than predicted, based upon their co-morbidities. Reference 1. Mekonso-Dessap A, Brun-Buisson C: Statins: the next step in adjuvant therapy for sepsis? Intensive Care Med 2006, 32:11-14. P432 How did you sleep in the ICU? LF Franck, DM Le Moullec, EB Batjom, NL Libert, JT Tourtier, SR De Rudnicki, MB Borne HIA Val de Grace, Paris, France Critical Care 2010, 14(Suppl 1):P432 (doi: 10.1186/cc8664) Introduction It has been proven that patients’ sleep is extremely disturbed in the ICU for many reasons: illness pathophysiology and severity, pain, or the ICU environment itself. The aim of our survey was to describe the memorization of sleep disturbances during an ICU stay and the patients’ reported sleep quality after critical care. We also assessed the possible underlying causes of sleep disturbances including factors related to the critical illness. Methods A telephone interview including a random sample of 60 patients admitted to our ICU (between December 2008 and May 2009) was performed 6 to 12 months after their discharge. Eight patients were excluded (two for language barrier, two were dead, four were not joined). Conventional intensive care variables were retrospectively recorded from the ICU database and sleep disturbances were evaluated using the Basic Nordic Sleep Questionnaire. Two nonvalidated questions were analysed, one estimated the quality of sleep in the ICU and the other compared the quality of sleep before and after the ICU stay. Data were presented descriptively using logistic regression to evaluate the independent efects of sex, age, BMI at admission, SAPS II, length of stay, hemodialysis, length of mechanical ventilation, length of central venous catheterization and prescription of vasopressor agents or transfusion. Results Among responding patients, 47% remembered sleep disturbances in the ICU and among them 43% still declared a decreased long-term quality of sleep. In addition, 30% of patients report a worse quality of sleep after the ICU than it used to be before. No relation was found when we assessed the possible efects of intensive care variables on the sleeping patterns during critical illness. Conclusions Sleep disturbances were described in one-half of the patients we studied during their ICU stay. As interesting (but alarming) is that one-third of the group declared having a worse quality of sleep a long time after their discharge from the ICU. The sleep disturbances were not afected by ICU factors but their high self-reported prevalence probably S145 reveals the necessity of protocols evaluating the efects of strategies to improve sleep quality in patients’ recovery of critical illness and long-term sleep. Reference 1. Friese RS: Crit Care Med 2008, 36:697-705. P433 Factors associated with longer stay on a surgical intensive care unit P Toomtong, M Raksakietisak Faculty of Medicine Siriraj Hospital, Bangkok, Thailand Critical Care 2010, 14(Suppl 1):P433 (doi: 10.1186/cc8665) Introduction The advance in medical care for surgical patients results in older patients, increasing medical problems, and complexities of operations in surgical patients. Therefore, these patients may require a longer stay in the surgical ICU (SICU). The aim of the present study was to evaluate the occurrence, clinical outcome, and predictive risk factors for the longer SICU length of stay in critically ill surgical patients in our general SICU. Methods This study was an observation study; after the approval of the IRB, all patients admitted to the SICU from the operating theatres during the study period from 1 June to 31 December 2004 were recruited to the study. Data collection consisted of initial patient assessment and demographics, underlying problems, SICU interventions and laboratory investigations for TISS-28 and SOFA scores within the irst 24 hours of ICU admission. Descriptive statistics and backward stepwise logistic regression were employed to study for independent factors associated with the longer length of SICU stay. Results During the 6-month study period, 562 patients were admitted to the SICU with an overall mortality rate of 6.23%, and the overall average length of stay in the SICU was 2.72 days. There were 99 patients staying in the SICU longer than 4 days, with a mean of 9.12 days in these patients. The independent associated factors of SICU stay longer than 4 days were perioperative cardiac complications, odds ratio (OR) 12.77 (95% conidence interval 4.52 to 36.08); P <0.01, requirement of ventilator support, OR 6.95 (3.13 to 15.42); P <0.01, bleeding in the SICU, OR 4.85 (1.33 to 17.65); P = 0.02, perioperative respiratory complications, OR 2.77 (1.09 to 7.02); P = 0.03, emergency surgical procedures, OR 2.47 (1.35 to 4.51);P <0.01, new haemodynamic monitoring interventions in the SICU, OR 2.28 (1.28 to 4.08); P <0.01, hypotensive episodes in the SICU, OR 2.27 (1.16 to 4.45); P = 0.02, and oliguria, OR 1.82 (1.03 to 3.22); P = 0.04. Conclusions The SICU patients who had a longer stay are associated with emergency procedures, the development of perioperative cardiac and respiratory complications, surgical bleeding, active monitoring interventions upon SICU admission, they were more likely to be hypotensive and had oliguria in the irst 24 hours of the SICU stay. Reference 1. Higgins T: Early indicators of prolonged intensive care unit stay: impact of illness severity, physician staing, and pre-intensive care unit length of stay. Crit Care Med 2003, 31:45-51. P434 Social support: a signiicant factor for health-related quality of life after critical illness? L Orwelius, M Fredriksson, C Bäckman, A Samuelsson, F Sjöberg Faculty of Health Sciences, Linköping, Sweden Critical Care 2010, 14(Suppl 1):P434 (doi: 10.1186/cc8666) Introduction Decreased health-related quality of life (HRQoL) is well known for the previous ICU population after critical care, and many factors are of importance for this outcome. We have in a recent study shown that pre-existing disease is most important. This inding was made when comparing a control population adjusting for co-morbidities and approximately 50% of the decrease in HRQoL was attributed to comorbidities. Therefore, there must be other factors that contribute to the HRQoL decrease. In HRQoL research it has been shown that social support also is important for the HRQoL experience. In the southeast of Sweden, two neighbouring large cities are known to have diferent social support patterns depending on their diferences in social structure. We hypothesized that the social support is diferent between the patients Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 coming from city A’s ICU compared with city B. The aim of this study was to examine to what extent social support afected HRQoL outcome in the follow-up of these patients in general and to what extent it difered between the patients of ICUs of the diferent cities. Methods Mixed ICUs from two hospitals in diferent cities. Questionnaires, including the social support instrument Availability of Social Integration (AVSI), the HRQoL scale SF-36, demographic data and previous illnesses, were sent 6 months after discharge to all adult patients. Results Six hundred and thirty-three (57%) patients returned the questionnaire, 371 from city A. The ICU patients from city B reported a signiicantly lower mean score in social support compared with city A, 18.3 (SD 6.3) compared with 19.6 (SD 6.5) (P = 0.013). The SF-36 scores in all subscales showed no signiicant diferences between the two cities. The results demonstrate that ICU patients with pre-existing disease have eight times higher risk of a decreased physical component score, and nearly six times higher risk of a decreased mental component score than the previously healthy patients. ICU patients with lower mean social support scores had 0.16 higher risks of a decreased physical score and 0.46 higher risks of a decreased mental component score. Conclusions This study indicates that social support has a signiicant, but small, efect on HRQoL in former ICU patients. Importantly, the magnitude of this efect was too small to be relevant in comparisons of HRQoL in former ICU patients from cities with diferent social structures within one country. Reference 1. Orwelius L, et al.: Crit Care Med 2005, 33:1557-1564. P435 Quality of the evaluations of clinical studies in adult critical care and emergency medicine on a specialized Internet site T Leclerc1, D Journois2 1 HIA Percy, Clamart, France; 2H. Européen G Pompidou, Paris, France Critical Care 2010, 14(Suppl 1):P435 (doi: 10.1186/cc8667) Introduction Given the huge publication low, tools helping intensivists to select articles worth reading and to appraise relevant information are welcome. Evaluations of selected articles on dedicated Internet sites could serve that purpose. Methods As a irst attempt to estimate the quality of such sites, we conducted a prospective observational study of www.f1000medicine.org (F1000). Consecutive adult clinical studies with a irst F1000 evaluation in the critical care and emergency medicine specialty were included. We recorded predeined items describing the internal validity, clinical relevance and external coherence of the studies and corresponding information in their evaluations. The primary endpoint was conformity of the conclusions to raw study results, compared between each study and its irst F1000 evaluation. Results Fifty studies with 56 evaluations (six articles evaluated twice) were included. Conclusions conform to factual study results in 52% of the studies, excessive in 30%, out of scope in 18%; conform in 36% of all evaluations, excessive in 25%, out of scope in 39%. The conformity level signiicantly difered between the studies and their irst evaluation (P = 0.026, Mantel–Haenszel chi-squared test). No association between conformity level and journal impact factor was observed in included studies (P = 0.84, Kruskal–Wallis test), neither in their evaluations between conformity level and publication-to-evaluation time (P = 0.46), evaluation length (P = 0.35) nor strictly article-focused relative length (P = 0.027, Bonferroni correction: NS). Regarding internal validity, out of 28 prospective studies (13 interventional), ive had been registered, three of which before study termination with publicly traceable protocol changes; registration was discussed in four out of 33 related evaluations. Alpha risk inlation was uncontrolled in 95% out of 41 nonpurely descriptive studies, but never discussed in their 46 evaluations. Out of 20 negative studies, 16 were underpowered (an unrecognized fact in 15 studies), but power was discussed in only ive out of 25 related evaluations. Clinical relevance was discussed in only 13% of F1000 evaluations. Regarding external coherence, 52% of F1000 evaluations did not relate study results to existing literature. Conclusions Our results suggest that F1000 evaluations often provide information poorly suited to critical appraisal of clinical studies by intensivists. Basing evaluations on assessment grids could improve their overall quality. S146 P436 Functional status and quality of life in patients sufering severe cranioencephalic trauma at the time of discharge from the intensive care unit and 1 year after E Curiel Balsera1, M Prieto Palomino1, M Delange2, A Muñoz1, JF Fernandez Ortega1, G Quesada García1 1 Carlos Haya Hospital, Málaga, Spain; 2Hospital de la Axarquia, Velez-Málaga, Spain Critical Care 2010, 14(Suppl 1):P436 (doi: 10.1186/cc8668) Introduction Results obtained after management of cranioencephalic trauma (CET) are referred only in terms of morbimortality. Our objective is to analyze physical and functional status after being discharged from the ICU, and the quality of life 1 year later. Methods Cohort study with adult patients admitted to the ICU from 2004 to 2008 with severe CET. Demographic, epidemiologic and clinical data were recorded. Validated measure scales used were GCS, GOS, ISS and the quality-of-life questionnaire PAEEC (Project for the Epidemiological Analysis of Critical Patients). Multivariate analysis identiied predictor factors of mortality. Results We included 323 patients with a median age of 32 years old, 79.6% males, who sufered severe CET secondary to traic (57.6%) or falling (29.8%) accidents. Cranial computed tomography (CT) scan most frequent indings were difuse injury III (30%) in Marshall classiication; ISS irst median was 33; APACHE II, 19; length of stay, 6 days (10 days if we take away those who died very soon); days on mechanical ventilator, 8. Total GCS at admission/discharge was 5/10 (P = 0.001). GOS 4 to 5 at discharge from the ICU was 14.4% and 1 year later was 54.1% (P = 0.001). Mortality in the ICU was 33.1%. Predictors of mortality were the length of stay (P = 0.0001), GCS at admission (P = 0.05), CT indings type III, IV and V (P = 0.014, 0.001 and 0.028, respectively), complications (P = 0.0001), tracheotomy (P = 0.028), days on ventilator (P = 0.0001) and APACHE II (P = 0.025). One year after discharge, 159 from 216 patients answered the questionnaire (73.6%): severe physiologic dysfunction, great dependence in activities of daily living and emotional disturbances were detected when leaving the ICU and marked as 59.3%, 88.6% and 70.1%, while 1 year after they were 18.9%, 32.1% and 35.8%, respectively (P = 0.0001). Conclusions Severe CET was usually caused by traic accidents, afected young adults and the mortality was over 33% in the ICU. Factors independently associated with increased mortality were coma level, type of indings in CT, complications, prolonged mechanical ventilation, length of stay, APACHE II, and the need for a tracheotomy. One year later, survivors showed a better GOS and physiologic capacity. Reference 1. Temkin NR, Corrigan JD, Dikmen SS, Machamer J: Social functioning after traumatic brain injury. J Head Trauma Rehabil 2009, 24:460-467. P437 Long-term (>6 years) quality of life after surgical intensive care admission T Timmers1, MJ Verhofstad2, LP Leenen1, KG Moons3, EF Van Beeck4 1 Universitair Medical Centre Utrecht, the Netherlands; 2St Elizabeth Hospital, Tilburg, the Netherlands; 3Julius Centre for Health Sciences and Primary Care, Utrecht, the Netherlands; 4Erasmus Medical Centre, Rotterdam, the Netherlands Critical Care 2010, 14(Suppl 1):P437 (doi: 10.1186/cc8669) Introduction Treatment of surgical patients in the ICU, afected by severe illnesses or injuries, should be justiied by an acceptable survival and longterm quality of life (QoL). The primary aim of this study was to quantify the long-term QoL (>6 years) of a large cohort of patients admitted to a surgical ICU. In addition, we aimed to explore the inluence of diferent surgical diagnosis groups on long-term health status and to make comparisons with general population norms. Methods QoL was measured in all surviving surgical ICU patients admitted to a Dutch teaching hospital between 1995 and 2000. Patientreported data on QoL were collected with the EuroQol-5D+ after a mean follow up of 8 (range 6 to 11) years. Patient characteristics, surgical diagnosis group, length of ICU stay and survival were prospectively registered. EQ-utility scores (EQ-us), EQ Visual Analogue Scales (EQ-VAS) Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 and prevalences of domain-speciic health problems were calculated. The efect of surgical diagnosis group on EQ-us/EQ-VAS was assessed by multivariable generalized linear regression analysis. Logistic regression was used to explore the inluence of surgical diagnosis group on domainspeciic health problems. Long-term quality of life of surgical ICU patients was compared with an age-matched and sex-matched general Dutch population using the t-test analysis. Results Eight hundred and thirty-four patients survived the ICU and were available for follow up. In 598 (72%) patients, the health-related QoL was measured. For all surgical groups combined, after 6 to 11 years nearly one-half of all patients still sufered from problems in the dimensions of mobility (52%), usual activity (52%), pain (57%) and cognition (43%). Compared with the age-matched and sex-matched general Dutch population, HRQoL was worse with a diference of 0.11 on the EQ utilities score (range 0 to 1). Oncological surgery patients had the best (EQ-us 0.83) and vascular patients had the worst (EQ-us 0.72) HRQoL. Trauma (odds ratio between 2.47 and 3.47) and vascular surgery (2.27 to 5.37) showed signiicantly increased prevalences of problems in mobility, self-care, usual activities and cognition. Conclusions More than 6 years after a surgical ICU admission, the QoL of this patient population is largely reduced. Many patients still sufer from a variety of health problems, including decreased cognitive functioning. Treatment advances should be made to reduce the current health deicit of surgical ICU survivors compared with the general population. P438 Children’s self-reported health-related quality of life after intensive care treatment G Colville1, C Pierce2 1 St George’s Hospital, London, UK; 2Great Ormond Street Hospital, London, UK Critical Care 2010, 14(Suppl 1):P438 (doi: 10.1186/cc8670) Introduction A number of studies have reported on parental/clinician reports of children’s health-related quality of life (HRQoL) after intensive care treatment [1]. The aim of this study was to establish children’s own views as to their outcome in this regard. Methods A cohort of 102 children aged over 7 years, with no preexisting learning diiculties, completed the PedsQL 4.0 Pediatric Quality of Life Inventory [2] and a post-traumatic stress screener in face-to-face interviews, 3 months after discharge from the PICU. Of this group, 76 also completed questionnaires, by post or telephone, at 12 months. Results Children’s total PedsQL scores were signiicantly lower than those of healthy children at 3 months (PICU mean = 79.3; healthy mean = 83.9, P <0.01), but at 12 months they were comparable. By 12 months, the mean score for the PICU group on the physical functioning subscale had improved signiicantly (from 73.1 to 81.5, P <0.001) but was still below normal population levels (healthy mean = 88.5, P <0.01). The total PedsQL score at 12 months was not associated with PIM score or length of stay, but was signiicantly negatively associated with post-traumatic stress symptoms (r = –0.40, P <0.001). Within-group analyses revealed that electively admitted children reported higher emotional functioning than healthy children at 3 months (PICU elective mean = 91.0 vs healthy mean = 78.5, P <0.01). Conclusions The self-report version of the PedsQL proved to be a feasible and responsive tool for assessing HRQoL in this group of PICU survivors. However, in order to assess this aspect of outcome for the majority of children admitted to the PICU, who are younger and/or have signiicant cognitive impairment, administration of the parent-proxy version of this questionnaire would be necessary. References 1. 2. Knoester H, Grootenhuis MA, Bos AP: Outcome of paediatric intensive care survivors. Eur J Paediatr 2007, 116:1119-1128. Varni JW, Seid M, Kurtin P: The PedsQLTM 4.0: reliability and validity of the Pediatric Quality of Life Inventory™ version 4.0 generic core scales in healthy and patient populations. Med Care 2001, 39:800-812. S147 P439 Activities of daily living (Barthel Index) at discharge from the intensive care unit CB Kancir, PK Korsgaard Regional Hospital West Jutland, Holstebro, Denmark Critical Care 2010, 14(Suppl 1):P439 (doi: 10.1186/cc8671) Introduction In order to continue optimal and adequate rehabilitation care in the nursing ward, information about the functional status of patients at discharge from the ICU is needed [1]. The Barthel Index is a simple index of independence to score the ability of a patient to care for itself. It measures the patient’s daily functioning, speciically the activities of daily living (ADL) and mobility [2]. The objectives of the present study were to assess the ADL of ICU patients at discharge to the ward, and to identify explanatory factors of functional status. Methods A prospective, observational, cohort study was conducted with patients who stayed in a six-bed mixed (predominantly medical) ICU for longer than 48 hours. We used the Danish-language version of the Barthel-20 Index, which is a validated and reliable generic instrument, to measure ADL. The Barthel Index measures the capacity to perform 10 basic ADL and gives a quantitative estimation of the patient’s level of dependency, with scoring from 0 (totally dependent) to 20 (totally independent). All assessments were carried out by critical care nurses with an experienced physiotherapist. Patient characteristics and outcome measures were analyzed with descriptive statistics. The data are expressed as medians and interquartile ranges. Results At discharge from the ICU, functional status (as primary outcome) was assessed in 73 patients. The overall functional status was poor (median Barthel Index 2; 0 to 9). In their ability to perform basic ADL, 63% were severely dependent, 25% were moderately dependent, and 10% were slightly dependent on other people. The transfer from bed to wheelchair and return with major help was the ADL component that was noted in the great majority of the patients. Duration of mechanical ventilation (median 5 days; 1 to 12 days) was associated with poorer functional status at ICU discharge. Conclusions This study provides information that is important for the planning of rehabilitation of patients at ICU discharge. After transfer to the ward, the physical resilience of critically ill patients is severely limited. This implies that prior assessment of any care needed after discharge from the ICU is very important. References 1. 2. van der Schaaf M, et al.: Disabil Rehabil 2008, 30:1812-1828. Mahoney FI, Barthel D: Md State Med J 1965, 14:56-61. P440 A comparison of Short Form 36 and Hospital Anxiety and Depression Scale based on patients 1 month after discharge from the intensive care unit CB Kancir Regional Hospital West Jutland, Holstebro, Denmark Critical Care 2010, 14(Suppl 1):P440 (doi: 10.1186/cc8672) Introduction Although the Hospital Anxiety and Depression Scale (HADS) and the health-related quality of life assessed by the Short Form 36 (SF-36) have been used concomitantly in several studies, extensive comparisons between HADS and the diferent components of SF-36 have previously been reported but not in ICU survivors. The aim of this study was to compare the scorings of anxiety and depression assessed by the HADS (HADA (Anxiety) and HADD (Depression)) with the scorings on the various domains of SF-36. Methods In a six-bed mixed (predominantly medical) ICU in a community hospital, 111 adult ICU survivors with a minimum stay of 72 hours were included. One month after ICU discharge or soon after hospital discharge they were sent the SF-36 and the HADS using regular mail. SF-36 tests eight domains. Four domains assess physical health, physical functioning (PF), role limitation due to physical problems (PR), bodily pain (BP) and general health perception (GH); while the other four assess psychological health, social functioning (SF), role limitation due to emotional problems (RE), energy and vitality (VT) and mental health (MH). The physical health summary score (PCS) relects PF, PR, BP, and GH. The mental health summary scale (MCS) relects VT, SF, RE, and MH. Pearson’s correlation coeicients were calculated on item and scale levels to assess the associations between the HADS and the SF-36 scales. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S148 Results HADA and HADD were signiicantly associated with MCS but not with PCS. The absolute r value between MCS and HADA (0.72) was signiicantly higher than the comparable igure between HADD and MCS (0.68). HADA explained 1% of the variance of PCS and 52% of the variance of MCS. The comparable igures for HADD were 2% and 47%, respectively. Diferences of correlation coeicients were further explored by evaluation of the associations between HADS and each of the eight SF-36 subscales. Only the association between HADA and PF was not statistically signiicant. Relatively high r values were observed between HADA (0.76) or HADD (0.65) and MH. The associations between HADA and MH exceeded signiicantly the analogue r values as to HADD. Conclusions This pattern of diferent predictions of the summary scales of SF-36 supports a clinical practice that anxiety and depression should be assessed separately. Additional use of a self-rating instrument for depression and anxiety, such as HADS, is recommended when SF-36 is used for quality of life assessment. P441 Post-traumatic stress disorder after surgical ICU admission C Aldecoa, S Pico, J Rico, B Vazquez, L Gomez, C Garcia-Bernardo, J Gomez-Herreras Universitary Hospital Rio Hortega, Valladolid, Spain Critical Care 2010, 14(Suppl 1):P441 (doi: 10.1186/cc8673) Introduction Post-traumatic stress disorder (PTSD) is a potentially serious psychiatric disorder that has traditionally been associated with traumatic stressors, such as participation in combat, having sufered violent assault, and survival after natural disasters. Recently, investigators have reported that the experience of critical illness can also lead to PTSD, although details of the association between critical illness and PTSD remain unclear. Our objective is to determine the prevalence and severity of symptoms related to the diagnosis of PTSD in a cohort of postsurgical ICU patients and to identify potential risk factors for PTSD symptoms. Methods A prospective cohort of patients over 18 years old, admitted to our surgical ICU for over 48 hours, between October 2002 and June 2008, were studied. Variables such as age, gender, type of admission, neoplasia, SOFA, ASA, APACHE II scores, surgical intervention, sepsis, renal failure, mechanical ventilation, cortocosteroid treatment, psychiatric history, blood product transfusions, and so forth, were recorded. The Post-Traumatic Stress Syndrome 10-Questions Inventory (PTSS-10) was used to measure the stress symptoms a year after discharge from the unit. Five hundred and one patients met the inclusive criteria, 198 died during the follow-up year after ICU outcome. Three hundred and three patients survived, 160 of them completed the questionnaire by telephone. The association of potential risk factors with PTSS-10 scores was done by logistic regression and multivariate analysis. Results PTSD prevalence was 13% in our unit. Statistical analysis shows the relationship between the syndrome and the following factors: female gender, age <65 years, mechanical ventilation, daily interruption of the sedation, previous psychiatric history and blood product transfusions. The multivariate analysis shows as independent risk factors: female gender, age <65 years, previous psychiatric history and blood product transfusions. Conclusions Our results agree with other authors about prevalence and most of the risk factors. Nonetheless we have found a positive relationship between interruption of sedation and the development of symptoms of PTSD as with psychiatric history. References 1. 2. Cuberthson BH, et al.: Post-traumatic stress disorder after critical illness requiring general intensive care. Intensive Care Med 2004, 30:450-455. Boer KR, et al.: Long-term prevalence of post-traumatic stress disorder symptoms in patients after secondary peritonitis. Crit Care 2007, 11:R30. P442 Health-related quality of life before intensive care B Wittekamp, D Tjan Gelderse Vallei Hospital, Ede, the Netherlands Critical Care 2010, 14(Suppl 1):P442 (doi: 10.1186/cc8674) Introduction We hypothesise that subjects admitted to the ICU have lower self-reported health-related quality of life (HRQOL) in Figure 1 (abstract P442). HRQOL pre ICU compared with the healthy population. the month before intensive care compared with the normal healthy population. Methods Potential participants were patients admitted for more than 48 hours to a 12-bed medical–surgical ICU. Patients or their proxies were asked to give informed consent and complete the SF-36. The SF-36 is a questionnaire measuring HRQOL on eight subscales [1]. The use of the SF-36 in proxies has been validated [2,3]. Participants were asked to complete the SF-36 based on the situation 4 weeks before ICU admission. SF-36 scores were compared with normative data (n = 1,742) [1], by independent t tests. Results Fifty-one questionnaires were completed, of which 28 (51.9%) were completed by a proxy. HRQOL before ICU admission was signiicantly lower on all SF-36 domains compared with the general population (P <0.0001) (Figure 1). This is in line with indings in one other Dutch survey [4]. Conclusions HRQOL before admittance to the ICU is lower compared with HRQOL in the normal healthy population. This is likely to contribute to the diminished HRQOL after ICU discharge. To measure the inluence of critical illness and ICU stay on HRQOL after an ICU stay, it is important to measure HRQOL before ICU admission. References 1. 2. 3. 4. Aaronson NK, et al.: J Clin Epidemiol 1998, 51:1055-1068. Hofhuis J, et al.: Intensive Care Med 2003, 29:974-979. Rogers J, et al.: Anaesthesia 1997, 52:1137-1143. Hofhuis JG, et al.: Chest 2008, 133:377-385. P443 Nursing staf development: strategies for success in a unique critical care unit in a developing country N Shwaihet, N Mohamad, E Saad King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia Critical Care 2010, 14(Suppl 1):P443 (doi: 10.1186/cc8675) Introduction Creation of innovative retention strategies is a major focus for nursing administration as a shortage of nurses recurs and turnover of staf becomes a problem. Retention strategies, to be efective, need to be targeted speciically to particular conditions of the nursing staf. The cardiac surgical intensive care unit (CSICU) at the King Faisal Specialist Hospital & Research Center is a unique unit that combines adult, pediatric and neonatal cardiac surgical patients. This demands well-trained and skilled nurses to be able to look after this complex variety of patients. The big majority of nurses recruited to the CSICU have an adult educational background only. Therefore the Department of Nursing Development and Saudization together with Cardiovascular Nursing Department developed and implemented diferent education strategies to improve nurse’s skills and competencies according to the unit’s needs. Methods The strategies implemented included: comprehensive and periodic assessment of nurses, regular inservices in the form of lectures, skill review sessions, a progressive orientation program divided into diferent phases, bedside teaching, provision of a wide educational references, and professional development workshops. Results In a survey done in 2006, from a database of 64 nurses, 18 (28%) had only adult experience. A total of 14/18 (78%) were unable to progress to pediatric care phase (PCP). Another survey in 2007 for a database of 68 Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 nurses showed that 15 (22%) had only adult experience. Eight out of 15 (53%) could not progress to PCP. A third survey performed in 2008, for a database of 82 nurses, showed that 25 (30%) had adult experience. Six out of 25 (24%) were not able to progress to PCP. Conclusions Implementing comprehensive education strategies targeting diferent approaches of training contributed to considerable progressive staf development and retention in the CSICU. References 1. 2. 3. Aiken LH, Buchan J, Sochalski J, Nichols B, Powell M: Trends in international nurse migration. Health Afairs 2004, 23:69-77. Atencio BL, Cohen J, Gorenberg B: Nurse retention: is it worth it? Nurs Econ 2003, 21:262-268, 299. Barney S: Retaining our workforce, regaining our potential. J Healthc Manag 2002, 47:291-295. P444 Implementing the Leapfrog standard in a developing country J Scribante1, S Bhagwanjee2 1 University of the Witwatersrand, Johannesburg, South Africa; 2University of Washington, Seattle, WA, USA Critical Care 2010, 14(Suppl 1):P444 (doi: 10.1186/cc8676) Introduction The Leapfrog standard of ICU physician staing is regarded as the gold standard. It is suggested that hospital leaders should focus on how to implement intensivist staing [1]. Internationally, especially in developing countries, the ‘how to’ poses a tremendous challenge. The Critical Care Society of Southern Africa identiied the need to objectively quantify existing ICU resources in South Africa (SA) with a view to making recommendations for the future. From this audit we discuss the challenges of implementing the Leapfrog standard of ICU physician staing in a developing country. Methods Approval to conduct a national audit was obtained from appropriate authorities and was undertaken in 2004 and 2005 in all public and private hospitals in SA. Results A 100% sample was obtained. At the time there were 448 units in SA, of which 7% of ICUs in the public sector and 1% in the private sector were closed units. There were a total of 4,168 ICU and HC beds, with 30 intensivists and 4,584 nurses (25% ICU trained) working in the ICU [2-4]. Conclusions SA ICU services face challenges and the results show the diiculty of implementing the Leapfrog standard. A strategy to deal with these challenges must be reality based and contextually appropriate. We propose short-term, medium-term and long-term recommendations that consider iscal pressure and competing healthcare imperatives [5]. Short term: Regionalisation and integration of ICU services, development of guidelines and protocols to guide practice. Introduction of continuous professional development programs and a structured outreach program for medical and nursing staf. Active recruitment and training of personnel. Medium term: Development of telemedicine and a two-tiered ICU program. The irst tier to comprise nurses and doctors with intermediate skills and experience. The second tier to comprise intensivists and fully trained ICU nurses. Both tiers to have a clear scope of practice, training and incentive schemes. A signiicant percentage of ICU beds are not in use due to various factors, these beds to be recommissioned. Long term: A strategy to convert open units to closed units over a period of time. New ICUs to be established as closed units. An up-to-date national ICU database to be maintained to direct future planning. References 1. 2. 3. 4. 5. Provonost PJ, et al.: Crit Care Med 2006, 34:S18-S24. Bhagwanjee S, et al.: S Afr Med J 2007, 97:1311-1314. Scribante J, et al.: S Afr Med J 2007, 97:1319-1322. Scribante J, et al.: S Afr Med J 2007, 97:1315-1318. Bhagwanjee S, et al.: S Afr J Crit Care 2008, 24:4-6. P445 Impact of thiopental use on cerebral perfusion pressure in severe brain trauma: an example of caregivers’ adaptation H Mehdaoui1, L Allart1, B Sarrazin1, R Valentino1, E Balestrat1, P Ravaux2 1 Fort de France University Hospital, Fort de France, Martinique; 2Lille 2 University, Lille, France Critical Care 2010, 14(Suppl 1):P445 (doi: 10.1186/cc8677) S149 Introduction Thiopental (TP) is used in severe brain trauma to control high intracranial pressure episodes. Deleterious side efects were described that questioned its ability to reach its objectives securely and eiciently. We analyzed the impact of TP use on cerebral hemodynamics and caregivers’ behavior towards recommendations using a high-rate recording information system. Methods A set of 813 hours of data were recorded at a rate of 0.5 Hz. The study was observational. Deleterious episodes were detected using the Information System (IS) and validated by two experts. We detected low cerebral perfusion pressure (CPP), high intracranial (HICP) and/or low mean arterial pressure (lMAP) episodes. We used commonly admitted threshold for the ICP (20 mmHg) and the CPP (60 mmHg). Medical orders intended to reach the recommended objectives were analyzed. Results Forty-eight periods stratiied according to TP dose were analyzed on 16 patients. Cumulative duration with TP was 20,520 minutes and 26,294 minutes without TP. The mean dose of TP administration was 250 ± 20 mg/hour (3.4 ± 1.4 mg/kg/hour). The HICP incidence was 85 ± 16 per 100 hours with TP vs 95 ± 29 without TP (NS). HICP duration was longer with TP (27 ± 2 vs 19 ± 2 minutes, P <0.005). The lMAP incidence was the same with or without TP (56 ± 19 vs 34 + 8 per 100 hours of monitoring). Duration of lMAP episodes was the same with or without TP (22 ± 2 vs 20 ± 2 minutes, NS). The incidence of orders intended to restore cerebral hemodynamics was equivalent in both situations (TP vs no TP, 79 ± 24 vs 104 ± 29 per 100 hours, NS). One hundred and eighty-eight medical orders were analyzed. Use of catecholamine was more frequent with TP (57% (n = 44) vs 43% (n = 33), P = 0.034). Conclusions The use of TP complies with the recommendations (prolonged HICP). It did not result in a signiicant increase in cerebral hypoperfusion episodes. We showed evidence of adaptations to its use by physicians. The doses are lower than the doses prescribed earlier in the literature and the use of catecholamine is more frequent during TP infusion. This could result in a better control of deleterious side efects of TP and a better compliance with recommendations. Our IS was eicient in physicians’ orders’ analysis. P446 Knowledge of ICU nurses regarding selected care areas commonly guided by protocols H Perrie, S Schmollgruber University of the Witwatersrand, Johannesburg, South Africa Critical Care 2010, 14(Suppl 1):P446 (doi: 10.1186/cc8678) Introduction Pain management, glycaemic control and weaning from mechanical ventilation are nursing care areas that can impact on patient outcome and are commonly guided by protocols. However, in order to ensure safe, optimal management of patients, even when care is guided by protocols, nurses require a sound knowledge base. This study attempted to describe the knowledge of ICU nurses regarding pain management, glycaemic control and weaning from mechanical ventilation, to compare the diference in knowledge between ICU-trained and non-ICU-trained nurses and to describe the impact of years of ICU experience on this knowledge. Methods A prospective, descriptive, non-interventional study method was used. Approval was obtained from the ethics committee and other relevant authorities. The questionnaire used was developed and validated by two groups of ICU nursing experts. The study population included all consenting ICU nurses working in the ICUs of the ive hospitals participating in this study. Results There were 136 participants in the study (68 ICU trained and 68 non-ICU trained). The mean score obtained was 47.56% (SD 11.61), the ICUtrained participants obtaining 50.11 (SD 11.96) and the non-ICU trained obtaining 45.01 (SD 10.75). This diference was statistically signiicant (P = 0.0099). The diference between the two groups for the section on pain management was not statistically signiicant (P = 0.408) with ICU-trained participants achieving a mean score of 45.07% (SD 16.01) and non-ICUtrained participants 42.86 (SD 14.91). The diference between the two groups for the other two sections was statistically signiicant (P = 0.025 and P = 0.006, respectively) with the ICU-trained group achieving 51.26% (SD 11.74) and the non-ICU trained 46.16 (SD 14.34) for the glycaemic control section and 53.99% (SD 18.18) for the ICU-trained participants and 46.01% (SD 15.18) for non-ICU-trained participants for the section Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 pertaining to weaning from mechanical ventilation. The correlation between knowledge and years of ICU experience was poor (r = 0.137). Conclusions This study found a lack of knowledge regarding the care areas tested, a small, but statistically signiicant diference between ICUtrained and non-ICU-trained nurses and a poor correlation between knowledge and years of ICU experience. P447 Pharmacist clinical interventions in the ICU NG Hunfeld, PH Melief, RM Van Hest, BE Bosma HagaTeaching Hospital, Den Haag, the Netherlands Critical Care 2010, 14(Suppl 1):P447 (doi: 10.1186/cc8679) Introduction We wanted to investigate the number and nature of pharmacotherapeutical interventions of a dedicated hospital pharmacist during rounds in the ICU. Methods A pharmacist specially trained in ICU practice participated in the patient rounds twice a week (from July to December 2008). The pharmacist focused on optimalization of pharmacotherapy based on ICU guidelines and standards as well as general pharmacotherapy. Medication overviews were generated from the ICU Patient Data Management System and were analyzed for each patient during the patient rounds. Interventions were made to comply with guidelines and to avoid interactions, contraindications, overtreatment and undertreatment and to recognize side efects. All pharmacist interventions were collected in a database and the percentage of interventions leading to a change in pharmacotherapy was analyzed. Results Fifty patient rounds were attended (160 patients, mean age: 64, male: 59%, mean APACHE II score: 25, mean length of stay: 8.7 days, number of drug orders analyzed: 4,227). A total of 342 interventions was made in 66% of patients (mean: 2.1 interventions/patient), resulting in a change in pharmacotherapy in 67% of the interventions. The kind of interventions were: start drug: 18%, stop drug: 15%, reduction of dosage: 3%, increase of dosage: 4%, toxicology: 12%, interaction: 6%, contra-indication: 9%, adverse events: 3%, double medication: 4%, switch in accordance to guidelines: 6%, software: 2%, dose reduction because of renal failure: 6% and other (for example, infusion incompatibility or administration by feeding tube): 13%. Classes of drugs most involved were: antiobiotics, gastrointestinal drugs and anticoagulants. Conclusions Frequent presence of a dedicated pharmacist during patient rounds in the ICU results in interventions in pharmacotherapy in 66% of the admitted patients. The mean number of interventions per patient is 2.1. Interventions lead to improved compliance with ICU guidelines and pharmacotherapy standards and warrants monitoring of pharmacotherapy. Interventions probably lead to improved eicacy and safety of pharmacotherapy, although future controlled research will have to prove to what extent drug-induced harm is prevented. P448 Adverse drug events in the critical care unit S Seynaeve, D Reyntiens, D Vandenplas, W Verbrugghe, B Claes, P Jorens University Hospital Antwerp, Edegem, Belgium Critical Care 2010, 14(Suppl 1):P448 (doi: 10.1186/cc8680) Introduction Mistakes and errors may occur during the care process, particularly in the ICU as characterized by its large number of drugs administered to the single patient. One of the most important inluencing factors on intramural morbidity and mortality is indeed a harmful or unpredicted reaction to a drug, a so-called adverse drug event (ADE) [1]. By far the largest proportion (70%) of these ADEs is dose related [1]. The objectives of this study are to measure the frequency and severity of ADEs in the ICU and to determine the inluence of severity of illness and nursing workload on their prevalence. Methods A cross-sectional study in the ICU of a tertiary referral hospital, based on a retrospective chart review. A tool was developed for measuring the incidence and characteristics of ADEs based on the Global Trigger Tool for Measuring Adverse Drug Events [2]. If an ADE was identiied the severity was evaluated using the categories based on the system for classifying medication errors by the National Coordination Council for Medication Error Reporting and Prevention [3]. The severity of illness was S150 calculated using the Sepsis-related Organ Failure Assessment score [4] and the nursing workload by the classical Therapeutic Intervention Scoring System-28 [5]. Results The review of 1,009 nursing days in 79 patients revealed 230 ADEs, which occurred in a total of 175 nursing days. The most commonly identiied ADE was a hypoglycemia of <50 mg/dl (n = 75), followed by hypokalemia (n = 67). Ninety-six percent of the ADEs were classiied as category E, whereas only 4% of ADEs were classiied as category F. The mean severity of illness and nursing workload scores were signiicant higher on nursing days when an ADE occurred (P <0.001 and P = 0.002, respectively). Conclusions ADEs are common in the ICU. The lack of a golden standard for reporting and collecting ADEs makes it diicult to compare with other studies and to assess the real value of this study. However, these date strongly and clearly indicate the inluence of severity of illness and nursing workload on the prevalence of ADEs. References 1. 2. 3. 4. 5. Nebeker JR, et al.: Ann Intern Med 2004, 140:795-801. Rozich JD, et al.: Qual Saf Health Care 2003, 12:194-200. National Coordinating Council for Medication Error Reporting and Prevention [www.nccmerp.org] Vincent JL, et al.: Intensive Care Med 1996, 22:707-710. Miranda DR, et al.: Crit Care Med 1996, 24:64-73. P449 Evaluation of appropriateness of intensive care unit admissions: the GIVITI’s StART approach R Rosi1, P Malacarne2, S Livigni3, D Radrizzani4, M Postiglione5, S Piva6, S Di Gangi7 1 AOUS, Siena, Italy; 2H S Chiare, Pisa, Italy; 3H S Giovanni Bosco, Torino, Italy; 4 H Legnano (MI), Milan, Italy; 5H Loreto Nuovo, Napoli, Italy; 6Spedali Civili, Brescia, Italy; 7Istituto Mario Negri Ranica, Bolognia, Italy Critical Care 2010, 14(Suppl 1):P449 (doi: 10.1186/cc8681) Introduction Appropriate use of ICU resources is mandatory. When a patient is admitted to a unit able to provide a higher (lower) level of care than required, a waste (overuse) of resources can be advocated. StART is an approach to identify possible mismatches between the level of care actually delivered, assumed to correspond to what is clinically required, and the level of care deliverable by the unit. Methods ICU beds are classiied by levels of care deliverable as High (ventilator, monitor, and 720 minutes nurse time) and Low (monitor and 360 minutes nurse time) [1]. The level of care actually delivered is classiied as High (invasive or non-invasive ventilation, or two vasoactive drugs, or at least two of the following: one vasoactive drug, dialysis, respiratory support), Low (single vasoactive drug, or dialysis, or respiratory support) and Ordinary (none of the above) [2]. Mismatches between the level of beds available and the level of care delivered were evaluated both on admission and for each ICU-day of 4,237 patients in 28 ICUs. An ICU-day was judged as inappropriate, even without mismatch, if an Ordinary patient was present. Results Eighteen percent of admissions resulted inappropriate (9% overuse, 9% waste of resources). Patients receiving H level of care (58% of the total) were appropriately admitted in 88% of cases. There were 271 patients admitted for Ordinary care (6%). They stayed in the ICU 2.5 days on average, and 95% of them had no complications. Sixty-eight percent of the ICU-days were inappropriate: 12% for overuse and 56% for waste of resources. Forty-two percent of the latter days were only due to the presence of Ordinary patients (43% of them were instead admitted as H or L patients). Conclusions Most of the ICU admissions (82%) were appropriate; the inappropriateness was mostly due to Ordinary patients treated. The short ICU stay and the absence of complications of these patients strengthen the inappropriateness of their admission, which was probably due to the lack of intermediate care units in Italy. The situation is completely diferent considering the ICU stay: the inappropriateness rose up to 68%, mainly due to the presence of Ordinary patients. Almost one-half of them were patients recovered from sicker condition, who were probably diicult to discharge from the ICU. References 1. 2. Iapichino G, et al.: Min Anest 2007, 73:501-506. Iapichino G, et al.: Intensive Care Med 2001, 27:131-136. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P450 Noise in the critical care environment N Haskins, J Soldan University Hospital of Wales, Cardif, UK Critical Care 2010, 14(Suppl 1):P450 (doi: 10.1186/cc8682) Introduction The subject of excessive noise levels within critical care is not new and has been identiied on numerous occasions in the literature. Research illustrates the detrimental efect of noise on patients both physically and psychologically. Our interest in this ield stemmed from Fundamentals of Care audits which described noise as being too high and disturbing for patients. Methods The extent of the problem was initially explored by undertaking an audit of noise using an on-the-spot soundmeter. This showed that noise levels were in excess of the World Health Organisation recommendations for a patient care environment [1]. This conirmed the need to address the subject of noise within our critical care unit. Noise levels were then investigated further using a Soundlog device. This enabled us to measure noise levels continuously over multiple 24-hour periods. The device measures the noise level every second and then records the average measurement every 5 minutes. Noise levels were audited over a 6-week period in a variety of locations in an efort to gain an accurate assessment of noise levels. In doing this, patterns and themes in levels of noise could be identiied and analysed. Results The audit showed that noise levels were consistently between 52 and 65 dB over a 24-hour period, which is above the WHO guidance of 35 dB and 40 dB limit. Conclusions The current noise levels within our unit exceed the recommendations so action needs to be taken to address this. It is a busy unit with some environmental noise origins but also a high density of staf and relatives, so with this in mind we are developing a project plan to enable us to explore the current levels of noise and its sources, identify those sources that are avoidable or open to modiication and enable staf to consider their role and responsibility in relation to noise reduction. By considering the issue of noise and developing strategies that result in sustainable reductions in noise levels, we are aiming to improve the patients’ experience of their critical care stay. We anticipate that there will be both practical and behavioural solutions to issues that arise, some of which can be addressed by quick-ix solutions while others will require longer term work. Reference 1. World Health Organisation 1999 Guidelines for Community Noise [whqlibdoc.who.int/hq/1999/a68672.pdf ] P451 Allergy documentation and transfer within critical care K Hatton1, N Barrett2, J Lim2, C McKenzie2 1 Chelsea and Westminster NHS Foundation Trust, London, UK; 2Guy’s and St Thomas’ NHS Foundation Trust, London, UK Critical Care 2010, 14(Suppl 1):P451 (doi: 10.1186/cc8683) Introduction Allergies to medication are common and potentially lifethreatening [1]. Patients enter critical care with incomplete information about their history. It is essential for safety that accurate allergy status is documented early in the critical care stay. This clinical audit (CA) was undertaken in a 43-bed, level 3 critical care unit to explore compliance with local guidelines on allergy documentation. Methods Critical care patient episodes were obtained retrospectively for a 1-month period. Timing of allergy documentation and drug prescribing was noted from the critical care electronic system (ICIP). Allergy status prior to the critical care admission and after discharge was noted from the ward drug chart. Additional allergy data were identiied from the hospital electronic patient record (EPR). The CA was repeated 1 year after implementation of recommendations. Results Patient episodes were collated (initial CA n = 58, repeat CA n = 79). A known drug/nondrug allergy was stated in 29.3% patient episodes during the initial CA and 39.2% patient episodes in the repeat CA. Allergy status was incomplete 24 hours after critical care admission for two patients at the initial CA with a reduction to zero during the repeat. Allergy status was incomplete prior to prescribing of a new drug in critical care (excludes luids, drugs required for emergency intubation) for 51.7% of patient episodes in the initial CA. This igure reduced to 19.0% in the repeat CA. Concordance S151 between EPR and ICIP allergy at the outset was 68.8%, which increased to 76.5% in the repeat CA. Concordance with the ward drug chart preadmission and ICIP was 77.6%, increased to 93.9% at re-audit. Conclusions This CA suggests that up to one in three critical care patients have a known allergy. The potential for harm is high. More than onehalf of patients admitted to critical care did not have an allergy status documented prior to prescribing a new drug. There was signiicant discordance between the paper medication chart and ICIP allergy. A number of factors were introduced following initial indings, including making the allergy status mandatory on ICIP, not allowing the admission summary to be saved prior to allergy documentation and ensuring current allergy documentation on EPR. Reference 1. Bates DW, et al.: JAMA 1995, 274:29-34. P452 Use of an anonymous medication incident reporting system on a critical care unit H Dillon, M Rosbergen, S Hutchinson Norfolk and Norwich University Hospital, Norwich, UK Critical Care 2010, 14(Suppl 1):P452 (doi: 10.1186/cc8684) Introduction An anonymous error reporting system was trialled to establish whether error reporting rates would improve and to allow the identiication of medication incidents. The National Patient Safety Agency (NPSA) feedback report for the Norfolk and Norwich Hospital shows that, compared with similar organisations, medication error reporting is low. A review of the medication incidents reported for the critical care facility in 2007 and 2008 had only 19 events. Error rates in the ICU are typically higher than in other acute settings, one study reporting 10.5 medication errors per 100 bed-days [1]. Patients in critical care typically receive highrisk medications. Error reporting is integral to identifying common errors and medication risk reduction. Methods A medication reporting form was developed to run alongside the oicial hospital incident reporting system for 2 weeks. Forms were distributed throughout the critical care facility. All members of the multidisciplinary team were asked to anonymously complete a form every time a medication error, or near miss, occurred. After 2 weeks, the submitted forms were analysed by the project team. Results In total 112 reports were submitted. The largest numbers of incidents reported were due to prescribing (67%) errors followed by administration (15%), documentation (7%), electronic prescribing problems (6%), storage (3%) and monitoring (2%). Within prescribing incidents there were four recurring themes: duplication of therapy, wrong/inappropriate drug choice, incorrect dose/regimen and omission. The numbers of incidents reported increased as the week progressed, with the largest number occurring on a Friday (24%). A review of the types of medicines involved showed that insulins, proton pump inhibitors, anticoagulants, vancomycin, and epidurals were recurring themes, relecting NPSA alerts. When graded for signiicance, two were found to be harmful, 56 signiicant and 54 insigniicant. Conclusions There is clearly considerable under-reporting of medication errors in critical care via the oicial incident reporting system. One of many reasons for poor oicial reporting of errors is the lack of tangible local response to those errors. It is therefore important that the areas highlighted by our project are efectively addressed, not only to improve safety but also to encourage further reporting and work to develop a culture of incident reporting within critical care. Reference 1. Valentin A, et al.: Intensive Care Med 2006, 32:1591-1598. P453 Three years experience of a quality improvement programme R Innes, S Burt, F Miles, S Watkins Musgrove Park Hospital, Taunton, UK Critical Care 2010, 14(Suppl 1):P453 (doi: 10.1186/cc8685) Introduction As part of a safer patient initiative under the auspices of the Institute of Health improvement (IHI), Boston, we took part in a 2-year project to improve the safety and quality of care in adult intensive care. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Figure 1 (abstract P453). Ventilator-associated pneumonias per 1,000 ventilator-days. C03: Musgrove Park Hospital, Taunton and Somerset NHS Trust. CCO1 – VAP rate. S152 (BP) in a step-down unit (both tools have been previously added to patient lowsheets), before and after the introduction of a structured rounds process and team education. Our hypothesis was that these important tools were used before rounds, without input from all team members. Rounds were observed on two separate periods and the observer would take notes of whether DG and BP were documented or not and whether discussion took place before documentation. Diferences in proportions between the two periods were analyzed with Fisher’s exact test. P <0.05 was considered signiicant. Results We observed 100 bedside interactions on each period. Documentation remained unchanged for DG (pre 55% vs post 53%, P >0.05) and BP (pre 57% vs post 48%); however, the second period had an improved documentation after team discussion (DG: pre 2% vs post 31%, P <0.001; BP pre 0% vs post 33%, P <0.001). Conclusions The intervention aided in increasing documentation after discussion, implying an increased communication among the interprofessional team. About 50% of patients still will not have documentation after bedside rounds. Patient information was not collected, therefore our study is limited in providing information on clinical outcomes. Further research should focus on how to best implement these tools, how to qualitatively assess the content of daily goals and to demonstrate efects on patient-centered outcomes. References 1. 2. 3. Figure 2 (abstract P453). Intensive care mortality between 2006 and 2009. Methods Between October 2006 and October 2008 the IHI coached and advised our institution on mechanisms to improve quality of care. The aim was to develop systems of healthcare that were reliable at least 95% of the time. The changes to be introduced – central line bundle, ventilator bundle, hand hygiene, daily patient goals – were led by a small multidisciplinary team chaired by a hospital executive (inance director) who met every 2 weeks for 2 years for short meetings (~1/2 hour). Our aim was to reduce nosocomial infection and mortality. Results It took ~12 months to introduce reliable process in all areas. Hand hygiene improved from ~70% compliance to consistently >95%. MRSA acquisition on the ICU reduced from about 10% of patients prior to October 2006 to 0.3%. VAP was reduced (Figure 1). The average unadjusted mortality was reduced year on year despite similar mean APACHE II and ICNARC scores (Figure 2). Conclusions Reliable evidence-based processes for patient care can signiicantly reduce nosocomial infection and mortality. The use of executive nonmedical hospital personnel experienced in the mechanisms of introducing change may be beneicial. Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO: Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care 2005, 14:401-407. Dodek PM, Raboud J: Explicit approach to rounds in an ICU improves communication and satisfaction of providers. Intensive Care Med 2003, 29:1584-1588. Gurses AP, Xiao Y: A systematic review of the literature on multidisciplinary rounds to design information technology. J Am Med Inform Assoc 2006, 13:267-276. P455 Stress induced by simulation-based training in anesthesiologist residents T Geeraerts, P Roulleau, G Cheisson, K Aidan, M Leguen, J Duranteau, D Benhamou CHU de Bicetre, Le Kremlin Bicetre, France Critical Care 2010, 14(Suppl 1):P455 (doi: 10.1186/cc8687) Introduction The use of a high-idelity simulator can lead to very realistic clinical situations sometimes diicult to manage psychologically. The aim of this study was to evaluate the psychological stress induced by simulationbased training and the associated skills in anesthesiologist residents. Methods A cohort of 27 residents was studied. The psychological stress just before and after the simulation session was quantiied by autoevaluation scale (numeric scale 0 to 10) and by salivary amylase sampling [1]. Nontechnical skills were quantiied by analysing videotapes and scoring the Anaesthetist NonTechnical Skills [2]. Results The median stress numeric scale before the simulation session was 5 (ranging 2 to 8), and after was 7 (2 to 10) (P = 0.0004) (Figure 1). The stress scale before the session was signiicantly lower in residents who already P454 Improving team work during bedside rounds: using daily goals and best practices M Adamson, L Kure, B Duncan, N Holmes, AA Amaral Sunnybrook Health Sciences Centre, Toronto, Canada Critical Care 2010, 14(Suppl 1):P454 (doi: 10.1186/cc8686) Introduction Communication between healthcare professionals is a key step for patient safety, its failure accounting for over 60% of root causes in sentinel events [1]. Bedside rounds are important for teamwork communication and can be improved by an explicit approach [2] and by process-oriented information tools to organize and direct interprofessional rounds [3]. Methods As part of a quality improvement project, we conducted an observation of the documentation of daily goals (DG) and best practices Figure 1 (abstract P455). Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 underwent simulation-based training (P = 0.04). In 48% of residents, stress scales after the simulation session were above 8/10. Salivary amylase after the session was signiicantly higher than before (P = 0.008), corresponding to a 2.2-fold increase. They were no signiicant relationships between psychological stress parameters and nontechnical skills. Conclusions Psychological stress before the simulation session, but especially after simulation, appears to be high in anesthesiologist residents, and particularly in those who performed a simulation session for the irst time. This fact should be considered when organising such simulation-based teaching. References 1. 2. Dantzer R, et al.: Psychoneuroendocrinology 2009, 34:1. Yee B, et al.: Anesthesiology 2005, 103:241-248. P456 Impact of an education program in respiratory therapy quality of care WA Pinto, HB Rossetti, A Araujo, HM Do Carmo, AP Acerbi, MV Santos, JJ Sposito, M Rabelo, SS Matos, M Assuncao, F Machado Federal University of São Paulo, Brazil Critical Care 2010, 14(Suppl 1):P456 (doi: 10.1186/cc8688) Introduction The respiratory therapist has a central role in the management of critically ill patients. The objective of this study was to evaluate the impact of an education program aiming to improve quality of care of respiratory therapy. Methods A before–after study was designed to assess compliance to 15 respiratory therapy indicators, chosen due to their relevance in patient care and availability for objective measurement, in all patients admitted to the ICU regardless of mechanical ventilation or not. Compliance was assessed during 1 month before implementation of the education program. The educational process comprised of meetings, group training, written manuals and individual feedback for noncompliance situations. After 6 months of the implementation process, compliance assessment was again performed. Results were expressed as percentages and comparisons were performed through the chi-square test. Results were considered signiicant if P <0.05. Results In both periods 80 patients were observed, with a total of 1,212 observations in the before period (BP) and 1,369 observations in the after period (AP). Compliance rates improved for almost all indicators as follows: chart registration (CR) of weight/height (BP = 97.7%; AP = 99.4%; P = 0.0026), CR of weight-predicted tidal volume (BP = 73.3%; AP = 94.7%; P = 0.000), CR of orotracheal tube ixation level (BP = 69.5%; AP = 93.6%; P = 0.000), CR of humidiication line change date (BP = 83%; AP = 89.8%; P = 0.000), CR of chest X-ray pattern (BP = 86.8%; AP = 96.9%; P = 0.000); CR of clinical decisions during round (BP = 91.3%; AP = 98.7%; P = 0.000), actual compliance to clinical decisions during rounds (BP = 79.77%; AP = 98.8%; P = 0.000), correct utilization of mechanical ventilation humidiication (BP = 75.9%; AP = 96.4%; P = 0.000), actual tidal volume between 6 and 8 ml/kg predicted body weight (BP = 82.0%; AP = 96.3%; P = 0.000), adequacy of ventilators alarms (BP = 69.5%; AP = 95.4%; P = 0.000), actual plato pressure <30 mmH2O (BP = 93.2%; AP = 95.7%; P = 0.0241). Some indicators did not show a statistically signiicant improvement: CR of secretion aspect (BP = 94.4%; AP = 94.2%; P = 0.861), CR of circuit change date (before = 90%; after = 92.2% P = 0.0848) and CR of round changes (BP = 92.0%. AP = 92.6%; P = 0.551). Only CR of cuf pressure had a lower compliance on the AP (BP = 87.5%; AP = 79.4%; P = 0.0005). Conclusions An education program based on protocol-driven actions and training is able to improve compliance in respiratory therapy quality indicators. The clinical relevance of this compliance improvement still needs to be established. P457 Use of the FAST HUG checklist in Mexican critically ill patients JC Cerda, V Sanchez, F Perez, E Fernandez HSJ Tec de Monterrey, Mexico Critical Care 2010, 14(Suppl 1):P457 (doi: 10.1186/cc8689) Introduction There have been several eforts to improve the quality of care of ICU patients. The use of checklists has been linked to improvements S153 in ICU care. In 2005, Vincent and colleagues published the FAST HUG checklist strategy [1]. We decided to study the level of adherence of Mexican physicians to the measures proposed in this checklist. Methods We conducted a 3-month prospective observational study in the adult ICU of an academic hospital in northeastern Mexico. Patients were sorted into one of the two study groups: group 1 had a critical care physician on charge of the ICU management, while group 2 had a noncritical care physician on charge. We measured the adherence of the physicians to the FAST HUG checklist items. We arbitrarily deined good compliance as having fulilled >4 items. Results One hundred and forty-seven patients were admitted to the ICU during the study period, but only 129 had complete data and were evaluated. There were 86 patients in group 1, while group 2 had 43 patients. Group 1 patients had higher age, SOFA and APACHE score on admission. We analyzed the subgroup of patients who had an initial APACHE score between 11 and 25, as they are usually the ones most likely to beneit from FAST HUG measures. These results are described in Table 1. We noticed that most of the group 1 patients had severe sepsis, while most of the group 2 patients had ischemic heart disease, which clearly explains the diferences in mechanical ventilation and length of ICU stay. Table 1 (abstract P457). Variables of the subgroup APACHE II 11 to 25 Variable Group 1 Group 2 P value Age 64 ± 10 69 ± 17 0.25 APACHE II 18 ± 5 15 ± 4 0.08 SOFA on admission 5±3 3.3 ± 2 0.12 SOFA at discharge 2.4 ± 4 1.7 ± 2 0.82 ICU length of stay 10.5 ± 9 4.6 ± 3 0.04* Mechanical ventilation days 6.7 ± 9.6 1.8 ± 3 0.11 FAST HUG 6.4 ± 0.9 3.8 ± 1.4 0.001* Group 1 had a critical care physician in charge of ICU management, while group 2 had a noncritical care physician in charge. We observed the same severity of illness in this group with APACHE II between 11 and 25 points and better adherence to the FAST HUG items among intensive care physicians. Conclusions We found a better adherence to the FAST HUG items among intensive care physicians. Reference 1. Vicent JL, et al.: Give your patient a fast hug (at least) once a day. Crit Care Med 2005, 33:1225-1229. P458 Bay rooms vs single-bed rooms in intensive care unit nosocomial infections: a case–control study E Bigazzi, L Turrisi, G Zagli, P Pecile, M Bonizzoli, A Peris Careggi Teaching Hospital, Florence, Italy Critical Care 2010, 14(Suppl 1):P458 (doi: 10.1186/cc8690) Introduction Nosocomial infections remain a clinical challenge in the ICU. Based on deinitions by the Centers for Disease Control and Prevention of Atlanta, nosocomial infections are deined as infection occurring within 48 to 72 hours after hospital admission. In ICU settings, a single-bed room location has been suggested as a structural organization helpful to prevent nosocomial infection difusion. Here we show preliminary results of a study conducted in our ICU before and after a change from open bay to single-bed room locations. Methods Microbiological data were collected from ICU patients hosted in bay rooms in the ICU (April 2006 to April 2007) and compared with data collected from patients hosted in the subsequent period (May 2007 to May 2008), after the single-bed ICU room re-allocation. For analysis, we considered the prevalence of microorganisms isolated and the diference in blood culture/tracheal aspirate positivity. Results The cohorts examined resulted in similar demographic and clinical data. As shown in Figure 1, microorganisms isolated did not change signiicantly in the two periods. Figure 2 summarizes the diferences in tracheal aspirate/blood culture isolation among the two periods. Conclusions We cannot conirm that a single-bed room location can prevent nosocomial infection difusion. A limit of this study, as in previous Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S154 Figure 1 (abstract P459). Comparing mean infection rates before and after the quality improvement process. Figure 1 (abstract P458). References 1. 2. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM: CDC deinitions for nosocomial infections, 1988. Am J Infect Control 1988, 16:128-140. Emori TG, Culver DH, Horan TC, et al.: National nosocomial infections surveillance system (NNIS): description of surveillance methods. Am J Infect Control 1991, 19:19-35. P460 Teaching airway resuscitation to novices: a randomized controlled simulator mannequin study P Brindley, C Needham University of Alberta Hospital, Edmonton, Canada Critical Care 2010, 14(Suppl 1):P460 (doi: 10.1186/cc8692) Figure 2 (abstract P458). published works, remains the bias related to patients admitted from other wards or after a prolonged emergency room stay. P459 Impact of quality improvement process on healthcare-associated infection in the ICU in a tertiary care hospital in India M Bhattacharyya, A Bhakta, S Todi AMRI Hospitals Kolkata, India Critical Care 2010, 14(Suppl 1):P459 (doi: 10.1186/cc8691) Introduction Healthcare-associated infection (HCAI) has a signiicant contribution to mortality, morbidity and cost of treatment in critically ill patients. The objective of this study was to conduct a process (quality improvement) and outcome (pre and post implementation) surveillance, HCAI being taken as the major variable. Methods This was a prospective observational study carried out from June 2005 to September 2009. Process implementation was started from May 2006 and included compliance with hand hygiene, urinary catheter care, central line care and VAP bundle. HCAI rates were recorded prospectively every month from June 2005. We recorded the rates of central line-related bloodstream infection (CLI), catheter-associated urinary tract infection (UTI), hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) per 1,000 device-days as per CDC–NNIS deinition [1,2]. Results Various infection rates showed numerical improvement after the implementation of the quality improvement (QI) process (Figure 1). The diferences were statistically signiicant for two of these four endpoints (P for HAP = 0.029 and for UTI = 0.013) and in others there was a trend towards improvement. Device utilization rates associated with these endpoints before and after the implementation remained unchanged, conirming that the drop of infection rates was not inluenced by any reduction/increase of respective device utilizations (Figure 1). The average compliance rate during the study period for hand hygiene was 77.92, for urinary catheter care 98.24, for central line care 96.62 and for VAP bundle 91.54. Conclusions Implementation and continuous surveillance of the QI process improved nosocomial HCAI in our hospital. Introduction The sniing position is widely promoted for teaching airway positioning prior to intubation attempts, but whether this analogy results in novices placing the head and neck appropriately has not been evaluated. An alternate analogy – win with the chin – or simple anatomic instructions may perform better. Methods Randomized controlled study comparing diferent instructions for enabling novices to adequately position a simulator mannequin’s head and neck. Study volunteers included medical students and PGY1 residents in surgery and internal medicine. Subjects independently positioned a mannequin based upon their understanding of four randomly-assigned written instructions for: the sniing position; the win with the chin analogy; anatomic instructions; and no instructions (control). Digital photographs following each instruction were analyzed by two airway experts for adequacy of overall positioning, and for the three components of airway positioning. Results There were 81 volunteers. The positioning was adequate most often (43.2%) following the win with the chin analogy as compared with the other instructions (37.0% anatomic instructions; 19.8% control; 14.8% sniing position analogy). Positioning following the sniing position instructions was not diferent from no instruction (P = 0.53). The win with the chin and anatomic instructions were better than no instructions (P = 0.002 and P = 0.023, respectively). Conclusions The win with the chin analogy resulted in adequate airway positioning signiicantly more often than the sniing position or control, and maintained atlanto-occipital extension when compared with providing anatomic instructions. Overall, win with the chin was a superior teaching analogy and could replace the sniing position analogy. P461 Impact of ultrasound guidance in central venous catheterization by inexperienced trainees: a prospective observational study S Yamao, R Suda, Y Tomishima, N Uchiyama, T Jinta, N Nishimura, S Ohde, N Chohnabayashi St Luke’s International Hospital, Tokyo, Japan Critical Care 2010, 14(Suppl 1):P461 (doi: 10.1186/cc8693) Introduction Central venous catheterization is a common procedure, but can potentially result in serious complications. Previous studies have shown that inexperienced trainees have lower success rates than experienced operators. Little is known about the eicacy of ultrasound (US) guidance in central venous catheter (CVC) insertion by inexperienced trainees. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Methods A prospective, observational study, performed in a Japanese training hospital. All patients who were inserted CVCs by inexperienced trainees (postgraduate year 1 to 6) between 1 June 2008 and 31 October 2009 were included. The following parameters were evaluated: the rate of successful insertions, the incidence of complications, the site of CVC insertion, the method of US use, and the postgraduate year of the trainees. We deined success of CVC insertion if a trainee completes catheterization without complication and personnel exchange. We compared the success rate and the complication rate with both insertion sites and US techniques; Group SA (surface anatomy) underwent CVC insertion using the landmark technique, Group indirect-ultrasound (iUS) using ultrasound image-based skin surface marking, and Group direct-US (dUS) using realtime ultrasound guidance. The chi-test was used for analysis and P <0.05 was considered statistically signiicant. Results In total 593 CVCs were inserted, 527 via the internal jugular vein (IJV), and 66 via the subclavian vein (SV). The IJV approach includes 52 patients (9.9%) in Group SA, 145 patients (27.5%) in Group iUS, and 330 patients (62.6%) in Group dUS. The SV approach, on the other hand, consisted of 26 patients (39.4%) in Group SA, and 40 patients (60.6%) in Group dUS. The success rate of CVC insertion of the IJV approach linearly rose in Group SA, Group iUS and Group dUS (76.9%, 81.4%, 88.2%, P = 0.033), but in the SV approach there is no signiicant diference between Group SA and Group dUS (76.9%, 75.0%, P = 0.83). Five patients who underwent real-time US via the SV developed pneumothorax while no one in Group SA had the complication (P = 0.57). Conclusions The use of ultrasound guidance improves the success rate of CVC insertion via the IJV by inexperienced trainees. However, in the SV approach the eicacy of ultrasound guidance is not proven, and the incidence of pneumothorax increased in our study. P462 Performance analysis of an ICU according to GiViTI’s StART approach R Rosi1, V Peccianti1, E Fatighenti1, M Giardino2, D Crespi2, A Anghileri2 1 AOUS, Siena, Italy; 2Istituto Mario Negri, Ranica (BG), Italy Critical Care 2010, 14(Suppl 1):P462 (doi: 10.1186/cc8694) Introduction ICU beds are a limited resource; their appropriate use is mandatory: only patients sick enough should be admitted to the ICU, and all admitted patients should receive the adequate level of care. Methods From 1 January 2008 to 9 March 2009, 716 admissions to a seven-bed general ICU were analyzed according to GiViTI’s StART approach, to evaluate appropriateness of the ICU admission and stay. Available resources (ICU beds) were classiied as High Level (HL) or Low Level (LL), according to equipment and staing. Patients may require High (H), Low (L), or Ordinary (O) levels of care (HP, LP, OP, respectively) [1]. OPs should not be admitted to the ICU and can stay in the ICU only briely, following HL or LL periods. One nurse can attend two HPs, or one HP and two LPs, or four LPs, provided that each bed can be controlled easily (not in diferent rooms, for example) [2]. For each day shift, matching of required and available care was analyzed: mismatch is expressed as nurse deicit: positive values indicate excess of care (too many nurses for not too sick patients), zero suggests that assistance requirements are met, with negative values available care is less than patients’ needs. Results In this ICU, all seven beds are fully equipped. Of the 716 ICU admissions, 20 (2.8%) were inappropriate OPs. One hundred and ninetyseven further ICU-days of the 2,711 available (7.3%) were used for OPs (mostly due to delayed discharges); altogether 217/3,427 (6.3%) ICUdays were inappropriately used for OPs. In the analysis of resources and requirements matching, if the seven beds were in the same room, available assistance would meet requirements in most nurse shifts, even if the staf would have worked at maximum almost always; in fact, in this ICU, four beds are in a room and there are three single-bed rooms – therefore, according to the suggested standards, a mean 1.9 nurse deicit per shift is observed. The relevance of this observation on patient outcome can be speculated only. Conclusions The relevance of the StART approach is the deinition of inappropriateness both from excess and insuiciency of care points of view: both admissions and ICU stays of OPs and/or too many too sick patients for the amount of care available are equally inappropriate. Moreover, the available care is determined both by the number of ICU S155 nurses and by logistic constraints: seven beds in an open space are diferent from four beds in a room and three beds in single rooms, and in fact this ICU pays a two nurse deicit per shift to its design. References 1. 2. Iapichino G, et al.: Minerva Anestesiol 2005, 71:273-280. Iapichino G, et al.: Minerva Anestesiol 2007, 73:501-506. P463 Simulation training at the point of care to decrease the incidence of airway complications on the intensive care unit SC Cook, JJ Gatward, FE Kelly, J Bell, FM O’Higgins, MJ Thomas Bristol Royal Inirmary, Bristol, UK Critical Care 2010, 14(Suppl 1):P463 (doi: 10.1186/cc8695) Introduction A recent analysis of critical incidents reported to the National Patient Safety Agency (NPSA) by ICUs in the UK revealed a signiicant number of airway incidents in critical care [1]. We recently performed an online survey with responses from 305 trainees from across the UK regarding airway management and complications on the ICU. The results revealed a high number of adverse airway events including 27 deaths. A large number of junior trainees (many of whom cover the ICU alone at night) expressed low conidence levels with airway management in critical care, and the majority of all trainees felt inexperienced with tracheostomy care and emergencies. Simulation has been recommended as a suitable way of providing critical incident training [2], and simulation at the point of care has been shown to be especially powerful and efective [3]. Methods In response to our survey, we set up a multidisciplinary simulation-based airway teaching programme for all staf on our unit. A Resusci-Annie™ manikin with an Airway Trainer™ head (Laerdel, Norway) is set up in a bed space on our ICU. Realistic patient monitoring is achieved with the Laerdel SimMan™ software (free from the Laerdel website). We have written a number of scenarios in response to incidents and training deiciencies highlighted by our survey. Scenarios are run with ICU staf from all disciplines acting within their normal roles. Realism is enhanced by staf practicing in their usual working environment, using the unit’s own equipment. Results So far, we have trained 43 ICU staf. Feedback has been excellent, with scores ranging from 8.5 to 10. Participants were especially positive about the multidisciplinary aspect of the training and on practising uncommonly encountered scenarios in their normal workplace. Conclusions We have created a multidisciplinary airway training programme to practice critical incident drills at the point of care. This teaching method is low cost, simple and can be set up quickly and spontaneously during quiet periods on the ICU. References 1. 2. 3. Thomas AN, et al.: Anaesthesia 2009, 64:358-365. Wheeler DW, et al.: Br J Anaesth 2009, 103:145-147. Weinstock P, et al.: Pediatr Crit Care Med 2009, 10:176-181. P464 Management of needle stick injuries from incapacitated patients L Burrows, A Padkin Royal United Hospital, Bath, UK Critical Care 2010, 14(Suppl 1):P464 (doi: 10.1186/cc8696) Introduction This survey investigated current UK intensive care practice in testing patients for blood-borne viruses following needle stick injury when the patient lacks capacity for consent. Needle stick injuries are a common occurrence in the National Health Service, with an estimated incidence of 113 to 623/10,000 healthcare workers/per year [1]. Current UK law [2,3] does not permit the testing of a patient’s infective status for the beneit of a healthcare worker involved without the patient’s consent. Incapacitated patients cannot give consent. The General Medical Council (GMC) guidance for the management of needle stick injuries from incapacitated patients relects this [4]. Methods A questionnaire was sent to the clinical lead of the 225 general ICUs within England, Wales and Northern Ireland. Responses were anonymous. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Results Ninety-nine consultants replied out of 225 (44% response rate). Sixty-two of the 99 consultants (63%) reported incidences of needle stick injuries to their staf from incapacitated patients in the past year. In six incidents the patient was not tested because their full blood-borne virus status was already known. Thirty-six of the remaining 56 incidents (64.5%) stated that patients were tested without consent. Sixty-one per cent of consultants (22 of 36) reported that the patient was informed once conscious that the test had been performed. Two consultants discussed the decision to perform the test with the family prior to proceeding. One patient, not tested at the time of injury, refused consent on regaining capacity. Sixteen patients out of the 62 incidents were blood-borne viruspositive (26%), six being new diagnoses following the needle stick injury (37.5%). Conclusions Despite the recent change in legislation, the majority of incapacitated patients are being tested for blood-borne viruses when unable to give consent. This has signiicant beneicial efects for the healthcare worker involved; a negative test allowing prophylactic antiviral treatment to be discontinued and minimises anxiety. This survey highlights the need for further discussion involving healthcare professionals, the legal profession and legislators regarding needle stick injuries from incapacitated patients. Is there a duty of care to the healthcare worker that is not acknowledged in current legislation? References 1. 2. 3. 4. Trim JC, et al.: J Hosp Infect 2003, 53:237-242. Human Tissue Act 2004 [http://www.opsi.gov.uk/acts/acts2004/ ukpga_20040030_en_1.htm] Mental Capacity Act 2005 [http://www.opsi.gov.uk/acts/acts2005/ ukpga_20050009_en_1] Update to Serious Communicable Disease guidance [http://www.gmc-uk. org/guidance/update_serious_communicable_diseases.asp] P465 Stress and fatigue among anaesthesia and intensive care doctors in Lithuania A Macas, A Kolciniene, I Vetaite, D Bilskiene, A Mikalauskas Kaunas University of Medicine, Kaunas, Lithuania Critical Care 2010, 14(Suppl 1):P465 (doi: 10.1186/cc8697) Introduction Evidence shows that anaesthesia and intensive care is a stressful occupation and it may have an impact on anaesthetists’ and intensive care doctors’ well-being. The goal of the study was to evaluate stress and fatigue and their correlation with working conditions among anaesthesiologists and intensive care specialists employed in Kaunas city (Lithuania) hospitals. Methods One hundred and forty-two doctors of anaesthesia and intensive care departments were interviewed using a standard questionnaire in 2008. It consisted of three parts: the irst part covered the demographic and social situation, second – stress experienced during work, third – risk of fatigue. Results The response rate was 71%. Average age of respondents was 41 years, 66.2% were female. A total of 25.4% had working experience <5 years and 23.2% working experience of 11 to 15 years. The workload of 49.3% of respondents was 37 to 54 hours per week (mean number of on-call nights per month – 6.5; 15.3% of respondents had >9 on-call night shifts). Often and very often stress was experienced by 24.6% of doctors; symptoms of fatigue were demonstrated by 57% of respondents. Respondents older than 55 years emphasized increased blood pressure, while younger respondents – up to 34 years – reported inability to concentrate, decreased objectiveness, unstable mood, diiculty in making decisions. Respondents living without partners experienced chest pain, anger and nuisance. Doctors experience less stress if they are satisied with their work and if their workload is adequate, while increasing pressure by hospital administration to decrease costs of care increased risk of fatigue. If a doctor is employed for more 40 hours per week he faces diiculties concentrating, while more than 60 hours per week causes interference with home life. Conclusions Every fourth anaesthesiologist experienced stress during work, while more than one-half had symptoms of moderate fatigue. Growing workload increased doctor’s stress. Pressure by hospital administration and limited freedom in decisions increased incidence of fatigue. Work satisfaction reduced risk of stress and fatigue. Stress and fatigue signiicantly correlated with the state of physical health. S156 P466 Implementation of daily goals in the ICU reduces length of ICU stay and errors of omission in patient care JM Binnekade1, A Brunsveld2, S Arbous2, MG Dijkgraaf1, J Horn1, J Sloot1, A Balzereit2, MB Vroom1 1 Academic Medical Center, Amsterdam, the Netherlands; 2LUMC, Leiden, the Netherlands Critical Care 2010, 14(Suppl 1):P466 (doi: 10.1186/cc8698) Introduction In the ICU, daily goals have improved the efectiveness of communication within care teams [1]. The study objective was to investigate the efect of explicit daily goals in ICU practice on the length of intensive care stay, length of hospital stay, duration of mechanical ventilation and errors of omission in patient care. Methods A multicenter, sequential cohort, pretest–post-test study was performed. During the pretest phase, daily goals were formulated by stafphysicians, evaluated by a research physician and kept blinded for the rest of the ICU team. Subsequently, daily goals were broadly implemented. During the post-test phase, daily goals were routine practice. Patient data were collected one full year before (as baseline reference) and during the pretest and post-test phases. During pretest and post-test, medical charts (random subsets of 10 patients a week) were reviewed for errors of omission, deined as deviations from our care protocols. Patient data were compared with data from nonparticipating academic ICUs, extracted from the National Intensive Care Evaluation database. Results Two academic ICUs participated in the study. Patients included: baseline reference n = 3,641; pretest n = 3,401, and post-test 3,426. ICU mean (SD) length of stay (days) difered signiicantly between the pretest phase 5.7 (2) and the post-test phase 4.3 (2.3), diference 1.4 days (95% CI 1.3/1.5). The post-ICU length of hospital stay decreased in the post-test phase, mean diference 2.3 days (95% CI 1.2/3.4). Median (IQR) duration of mechanical ventilation during pretest was 2 (1 to 4) days and during posttest was 1 (1 to 4) days, P <0.001. The probability of an error of omission was signiicant larger in the pretest phase then in the post-test phase, RR 6.5 (5.7/7.4). Conclusions The results showed a signiicant decrease in ICU LOS, duration of mechanical ventilation and length of post-ICU stay following DGF implementation. Also the chance of errors of omission to occur was six times lower, which indicates a signiicant increase in protocol adherence. The drawback of the study design (historic control group and a pretest and post-test for comparison) was limited by comparing the study results with other academic centers during the same time frame. Reference 1. Pronovost PJ, et al.: J Crit Care 2003, 18:71-75. P467 Use of single patient rooms to decrease acquisition of antibioticresistant bacteria in the ICU PD Levin, M Golovanevski, AE Moses, CL Sprung, S Benenson Hadassah Hebrew University Hospital, Jerusalem, Israel Critical Care 2010, 14(Suppl 1):P467 (doi: 10.1186/cc8699) Introduction The role of isolation rooms in decreasing bacterial transmission between ICU patients has been debated. A recent change in ICU location allowed for further investigation. Methods Old ICU A and Old ICU B were open-plan seven-bed and four-bed units. In March 2007, ICU A moved to single patient rooms (New ICU A – eight beds). ICU B remained unchanged (New ICU B). The same physicians cover both ICUs. Patient distribution is based on available space only. Demographic and microbiological data were collected on consecutive patients staying >48 hours. Culture of resistant organisms (MRSA, VRE, ESBL, resistant Acinetobacter, or carbapenem-resistant Gram-negatives) in surveillance or clinical cultures was measured. New ICU A was compared with open-plan New ICU B to assess the efect of single rooms. New ICU A was compared with Old ICU A to assess change vs historical controls and New and Old ICU B were compared with show control group stability. Results Data were collected on 62, 62, 44 and 39 patients from Old ICU A, New ICU A, Old ICU B and New ICU B. Patient populations in New ICU A and B were similar. ICU acquisition of resistant organisms was lower in New ICU A (3/62, 5% vs 7/39, 18% New ICU B patients, P = 0.043). This inding was conirmed using survival analysis (P = 0.011). Comparing New with Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Old ICU A showed lower APACHE II scores (18 ± 9 vs 21 ± 9, P = 0.028), preICU antibiotic use (20/62, 32% vs 37/62, 60%, P = 0.001), pre-ICU hospital admission (21/62, 34% vs 37/62, 60%, P = 0.004) and ICU admission prevalence of resistant organisms (11/62, 18% vs 25/62, 40%, P = 0.006). On Cox regression only the admitting ICU was signiicant for acquisition of resistant organisms (Old vs New ICU A: HR 4.07, 95% CI 1.03 to 16.06, P = 0.025). Comparing New with Old ICU B showed no changes. Adequate hand hygiene amongst the same physicians was found on 140/242 (58%) occasions in New ICU A vs 23/66 (35%) in New ICU B (P <0.001). Conclusions The change in ICU design to single patient rooms signiicantly decreased acquisition of multiresistant organisms. Whether the ICU design or improved infection control awareness led to change could not be determined. This is the irst study to measure the efect of ICU design on acquisition of a range of resistant organisms while including a contemporaneous control ICU environment. P468 Time to irst review of new admissions to critical care by the consultant intensivist A Dhrampal Norfolk and Norwich University Hospital, Norwich, UK Critical Care 2010, 14(Suppl 1):P468 (doi: 10.1186/cc8700) Introduction The National Conidential Enquiry into Patient Outcome and Death (NCEPOD) recommends that all new admissions to the ICU should be reviewed by a consultant intensivist within 12 hours [1]. This early review may reduce the ICU length of stay (LOS), but does not appear to afect mortality [2]. Patient severity of illness (APACHE II scores) may also inluence patient outcome. Methods The database of our clinical information system (MetaVision, iMDsoft) was interrogated and 116 new consecutive critical care admissions were retrospectively reviewed. We ascertained the time to irst review (in hours) by a consultant intensivist from MetaVision entry logs. Patient outcomes including mortality and LOS were also captured for patients reviewed early (<12 hours) and late (>12 hours). The admission APACHE II score was also calculated. Continuous and ordered categorical variables are expressed as the median and analysed by the Mann–Whitney U test. Outcome binary variables were analysed by the chi-squared test. P <0.05 was considered statistically signiicant. Results The early reviewed group (n = 53) had a median irst review time of 4.35 hours (IQR 1.70 to 6.90), median LOS of 46 hours (IQR 22 to 86) and mortality of 17% (n = 9). The late review group (n = 63) had a median irst review time of 16.55 hours (IQR 14.35 to 18.88), median LOS of 25 hours (IQR 20 to 46) and mortality of 1.6% (n = 1). The median admission APACHE II score for the early group and late group was 14 (IQR 10 to 24) and 10 (IQR 8 to 16), respectively. There was no signiicant diference in LOS between the two groups (P = 0.137, two-sample Mann–Whitney U test). The early group had a signiicantly higher mortality (P = 0.03, chi-squared test) and admission APACHE II score (P = 0.04, two-sample Mann–Whitney U test). Conclusions We were unable to demonstrate that early consultant intensivist review of new critical care admissions reduces the LOS or mortality. Despite early consultant intensivist review, this group had a signiicantly higher mortality. A signiicantly higher severity of illness in the early group may account for this higher mortality. References 1. 2. An Acute Problem? A Report of the National Conidential Enquiry into Patient Outcome and Death; 2005 [www.ncepod.org.uk] Mullen P, et al.: Timing of irst review of ICU admissions by consultant intensivists in a UK district general hospital. Crit Care 2009, 13(Suppl 1):P476. P469 Analysis of critical care referrals M Dallison, H Jones, P Matthews Morriston Hospital, Swansea, UK Critical Care 2010, 14(Suppl 1):P469 (doi: 10.1186/cc8701) S157 Recent UK guidance has recommended consultant-to-consultant referral for critical care patients [1]. Our ITU welcomes the timely referral of at-risk patients. However, excessive numbers of poor referrals have contributed to the prolonged absence of critical care team members from the unit. At a time of increasing diiculty in maintaining adequate levels of medical cover because of regulations concerning hours of work and training requirements, there is concern that this may adversely afect the eicient and safe management of the ITU. Methods All referrals were prospectively recorded for a 6-week period. The following data were recorded: date/time of referral, grade/specialty of the referring doctor, involvement of the referring consultant, indication for the referral, referral to assessment time, duration of the assessment and whether the referral led to admission. Results Fifty-seven per cent of referrals were out of working hours. The sources of the referrals were as follows: emergency codes 29% and specialty referrals 71%. The admission rates to the ITU for the referrals were cardiac arrests 33%, trauma calls 75%, specialty referrals 42%. Referral rates according to grade (excluding emergency codes): consultant 14%, senior trainee 49%, junior trainee 37%. Admission rates according to grade of referral: consultant 54.6%, senior trainee 42.1%, junior trainee 34.4%. The mean time to review of referral was 20.2 minutes. The mean time for assessment for all referrals was 38.8 minutes. This was 52.3 and 28.9 minutes for patients admitted to the ITU and not admitted, respectively. The mean assessment and management times for the code calls were: cardiac arrest 42 minutes and trauma calls 81.2 minutes. Conclusions Our data suggest that consultant-to-consultant referral would reduce ITU referrals that do not require admission, and decrease the time that ITU trainees are of the unit. Reference 1. P470 Communication with intensive care patients R Likar1, V Langhold2, A Kovinjalo1, H Trabe1 1 LKH Klagenfurt, Austria; 2FH Kaernten, Feldkirchen, Austria Critical Care 2010, 14(Suppl 1):P470 (doi: 10.1186/cc8702) Introduction Communication with conscious patients who are on oxygen and cannot verbally communicate due to temporary loss of speaking ability has proven to be anywhere from problematic to extremely diicult for the nursing staf trying to understand the needs of the patients. Methods In order to improve the situation of conscious patients on oxygen, it is irst necessary to conduct a status quo analysis to determine which communication aids can be implemented in the care of such patients. For this reason, a questionnaire was designed and carried out with the staf of the ICU. Results The questionnaire of the intensive care staf showed that from 31.7% (20 staf members), the use of diverse electronic aids was indicated 10 times as a means for improvement in the communication situation of conscious patients on oxygen. A further question regarding communication aids that the intensive care staf would like – but are not available in the ward – resulted in the computer being named as the most wanted communication aid. In cooperation with the engineering secondary school (HTL Mössingerstraße) a special keyboard was developed especially to suit the needs of conscious patients on oxygen and an operating system was installed on computers the general hospital made available. Conclusions The results indicated that the communication between the patients and the nursing staf using the computer showed a 50% improvement in understanding the needs of the patient from the point of view of the nursing staf. Thirty percent of the patients had tracheotomies and 20% were aphasia patients. References 1. 2. Introduction Anecdotal evidence at our hospital suggested an increase in the number of patients referred for admission to the ITU by junior doctors without consultation with senior doctors from their own specialty. An Acute Problem? A Report of the National Conidential Enquiry into Patient Outcome and Death; 2005 [www.ncepod.org.uk] Bazlen U: Plege bei Lungenerkrankungen. In Plege heute. Lehrbuch und Atlas für Plegeberufe. 2nd edition. Edited by Menche N, Bazlen U, Kommerell T. München: Urban & Fischer Verlag; 2001:703-742. Besendorfer A: Das Erleben von Patienten auf Intensivstationen. In Fokus Intensivplege. Plegewissenschaftliche Erkenntnisse zu Critical Care Nursing. Edited by Abt-Zegelin A. Hannover: Schlütersche Verlagsgesellschaft; 2004:95-158. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P471 Quality of transfers of critically ill patients within the hospital C Tjen, D Rowland, A Dhrampal, S Hutchinson Norfolk and Norwich University Hospital, Norwich, UK Critical Care 2010, 14(Suppl 1):P471 (doi: 10.1186/cc8703) Introduction Transferring critically ill patients between clinical areas is recognised to be potentially hazardous [1] and associated with poor outcome [2]. This study addresses the standard of intrahospital transfer of sick patients within our Trust including monitoring, equipment availability, personnel and training. Methods We surveyed senior ward staf on how they would conduct the theoretical transfer of a deteriorating, hypoxic, shocked patient to the ITU. Monitoring and equipment deemed necessary and its perceived availability were recorded, as was transfer personnel. We then prospectively reviewed actual transfers of patients with Early Warning Scores (EWS) of 3 or greater. Results Theoretical transfer data were collected from 19 wards. Most (74%) requested oxygen saturation (SpO2) monitoring, while less than one-third wanted either non-invasive blood pressure or ECG monitoring. Some wards expressed a need to borrow equipment, while others felt this would lead to delay. Three wards considered any monitoring unnecessary. Of 13 wards declining a deibrillator/cardiac monitor, two did so due to lack of familiarity. Prospective data were gathered from 32 transfers between September and November 2009. EWS ranged from 3 to 9. The actual transfer monitoring mirrored the initial survey, but for SpO2 monitoring (44% vs 74%, respectively). A doctor was included by 10% for the theoretical transfer and in 16% of actual transfers. Less than one-half of actual transfers had a trained member of the transfer team. These patients were better monitored but the standard of transfers did not correspond to EWS. Patients with higher EWS were neither better monitored nor accompanied. Out of hours activity comprised 21% of actual transfers. The bulk of patients were from the admission units and the majority went to critical care or radiology. Conclusions There is considerable movement of sick patients around the hospital. Many transfers are performed by untrained staf, without adequate monitoring, and many are out of hours. There is poor understanding of risks of transfer and of appropriate monitoring. The data suggest that deicits are due partly to equipment unavailability – we are conducting a further audit to determine this. We propose additional investment and training and are compiling intrahospital transfer guidelines according to EWS. References 1. 2. Waydhas C: Crit Care 1999, 3:R83-R89. Voight L, et al.: J Intensive Care Med 2009, 24:108-115. P472 Are bariatric patients putting a strain on intensive care beds? W Rutherford, H Wydell, S McAulife, C Peters Homerton University Hospital, London, UK Critical Care 2010, 14(Suppl 1):P472 (doi: 10.1186/cc8704) Introduction This study looks at the characteristics and outcomes of patients admitted to an ICU after bariatric surgery and considers the staing and inancial implications for the National Health Service (NHS). There is currently increased government incentive to treat obese patients with bariatric surgery with the aim of reducing co-morbidities in the future. Methods A retrospective analysis of bariatric surgery patients requiring an ICU admission between 1 February 2007 and 31 August 2009. The study was carried out in a nine-bed mixed medical and surgical adult ICU providing level 2 and level 3 critical care to a 430-bed hospital in East London with a regional laparoscopic bariatric surgery service. Medical records were reviewed and information including gender, body mass index (BMI), age, reason for admission, treatment required and length of stay in the unit was collected. APACHE II and SOFA scores were calculated. Results A total of 502 bariatric operations were performed during this period. Twenty-four (4.8%) patients required ICU admission at a cost of £2,500 (€2,750) per day for an average of 8.7 days (range 1 to 48). The average length of stay for all elective admissions was 2 days and for emergency admissions was on average 10 days. Cumulatively, bariatric patients spent a total of 209 days on the unit costing £522,500 (€575,300). S158 The average weight was 146 kg (range 71 to 320 kg). The average BMI was 53.3 (range 32.1 to 102.1). The age range was 24 to 69 (mean 48) with an average APACHE II score of 13 and average SOFA score of 5. Four admissions (17%) were elective, due to severe co-morbidities, extreme weight or anticipated airway diiculties. Seven patients needed to go back to theatre one or more times for re-exploratory surgery due to postoperative complications. Three patients remained intubated for 19 days or more, two of whom required a tracheostomy. Three patients died; two from intra-abdominal haemorrhage and one from sepsis. Conclusions This is a high-risk cohort of patients, with 4.8% requiring an ICU admission. The need for patients to return to theatre for re-exploratory surgery was associated with longer ICU stays and multiple complications. This demand on critical care services is likely to increase as bariatric surgery continues to grow as a specialty and the NHS will need to increase investment in ICUs accordingly. P473 Five-year evolution of drug prescribing in a university adult intensive care unit P Voirol, P Eggimann, C Carron, A Pannatier, R Chiolero, JB Wasserfallen University Hospital (CHUV), Lausanne, Switzerland Critical Care 2010, 14(Suppl 1):P473 (doi: 10.1186/cc8705) Introduction Drug prescription is diicult in ICUs as prescribers are many, drugs expensive and decisions complex. In our ICU, specialist clinicians (SC) are entitled to prescribe a list of speciic drugs, negotiated with intensive care physicians (ICP). The objective of this investigation was to assess the 5-year evolution of quantity and costs of drug prescription in our adult ICU and identify the relative costs generated by ICP or SC. Methods Quantities and costs of drugs delivered on a quarterly basis to the adult ICU of our hospital between 2004 and 2008 were extracted from the pharmacy database by ATC code, an international ive-level classiication system. Within each ATC irst level, drugs with either high level of consumption, high costs or large variations in quantities and costs were singled out and split by type of prescriber, ICP or SC. Cost igures used were drug purchase prices by the hospital pharmacy. Results Over the 5-year period, both quantities and costs of drugs increased, following a nonsteady, nonparallel pattern. Four ATC codes accounted for 80% of both quantities and costs, with ATC code B (blood and haematopoietic organs) amounting to 63% in quantities and 41% in costs, followed by ATC code J (systemic anti-infective, 20% of the costs), ATC code N (nervous system, 11% of the costs) and ATC code C (cardiovascular system, 8% of the costs). Prescription by SC amounted to 1% in drug quantities, but 19% in drug costs. The rate of increase in quantities and costs was seven times larger for ICP than for SC (Figure 1 overleaf ). Some peak values in costs and quantities were related to a very limited number of patients. Conclusions A 5-year increase in quantities and costs of drug prescription in an ICU is a matter of concern. Rather unexpectedly, total costs and cost increases were generated mainly by ICP. A careful follow-up is necessary to try inluencing this evolution through an institutional policy co-opted by all professional categories involved in the process. P474 A semiquantitative assessment of the efects of delayed discharge from the intensive care unit of survivors of critical illness P Hopkins, J Shrosbree, M Mekki, C Bell, A Feehan, K Peters Kings Health Partners, London, UK Critical Care 2010, 14(Suppl 1):P474 (doi: 10.1186/cc8706) Introduction One consequence of pressure on inpatient hospital bed numbers is a delay in the discharge of critically ill patients to the ward. Although this delay in discharge has been reported in a number of countries, the clinical and economic consequences of this delay have not been studied [1,2]. Methods We examined data from a mixed London ICU (32 beds) using the medtrack software tool (MASH Ltd) in addition to real-time mapping of ICU bed utilisation and patient lows. We deined delayed discharge as beginning 3 hours after the actual medical/nursing decision to discharge. We described a set of criteria a priori, to assess the efect of delayed Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S159 Ͳ1'400'000 Ͳ1'200'000 y=Ͳ77068x+2E+08 COSTS DRUG PRESCRIBED BY ICP Costs in Swiss Francs Ͳ1'000'000 Ͳ800'000 y=Ͳ67838x+1E+08 COSTS DRUG PRESCRIBED BY SC Ͳ600'000 600'000 Ͳ400'000 TOTAL DRUG COST Ͳ200'000 y=Ͳ9230.3x+2E+07 0 2004 2005 2006 2007 2008 Year Figure 1 (abstract P473). Costs by type of prescriber. patient discharge, searching for both beneicial and harmful efects. We also analysed the economic consequences of discharge delay using the medtrack capture of the critical care minimum dataset and available tarifs. Results In the 6-month analysis period, there were 15,320 hours of delayed discharge. This resulted in the postponement/delay of 45 operations for patients requiring level 3 intensive care and 177 operations for patients requiring level 2 intensive care. One hundred and fourteen tertiary referrals were refused because of bed blockage. Seventy-two patients were discharged between the hours of 22:00 and 06:00. There was a mean delay of 5.3 hours between identifying a patient requiring unplanned admission to critical care and their actual admission due to delayed discharge. Only 21 patients acquired a hospital-acquired organism while awaiting discharge (seven infections). Family/patient interviews suggested that the negative efects of noise and exposure to the resuscitation and/or death of ICU patients were ofset by a perceived beneit of receiving critical care nursing for a prolonged period. This potential beneit was relected by a 72% reduction in the readmission of critically ill patients to critical care. The estimated cost of delayed discharge was £342,000. Conclusions Delayed discharge of patients to the ward following an episode of critical illness is a common and increasing problem. This delay is not benign and should be considered when prioritising bed utilisation in acute hospitals. References 1. 2. which include emergency rooms (ERs) and ICUs during the second wave of an inluenza AH1N1 outbreak in Mexico. The program includes: rounds at the ACF and isolation area for patients with inluenza-like syndrome (ILS) every day from 9 am to 15 pm from Monday to Friday given by the MPH specialist team (intensivist), mechanical ventilation supervision (MV), transfer from CHs to high-care hospitals, length of stay (LOS) and mortality. Additionally, interventions in critically ill patients were recorded. Results From 3 October to 30 November, 56 patients with ILS were assisted by the MPH team: three patients in Atlacomulco CH, six in Valle de Bravo CH and 47 in Tejupilco CH. The mean age was 45.3 years old (from 19 years to 84 years), 32 were female (57%). A conirmatory test for AH1N1 was documented in 10 patients (17.8%). Patients assisted in the ER, three; in the ICU, nine; in the isolation area for inluenza, 44 patients. The mean LOS for all patients was 3.6 days, 3.4 days for patients in the isolation area, 6.5 days in the ICU and 1 day in the ER. There were ive patients on mechanical ventilation (8.9%) and two patients were pregnant (3.5%). Mortality was observed in ive patients (8.9%) and the mortality rate in the ICU was 50%. Additionally, two patients were transferred to a high-care hospital (one died). All patients who went on ventilatory support died during the irst day on MV. Conclusions This preliminary report shows that the practice of telepresence using robots at acute care facilities during an inluenza outbreak is feasible at CHs in Mexico. Williams T: Aust Health Rev 2004, 28:87-96. Levin PD: J Crit Care 2003, 18:206-211. P475 Robotics telepresence in acute care facilities during inluenza AH1N1 outbreak in Mexico GV Vazquez de Anda1, A Salinas Arnaut2, R Camacho Beiza2, O Macedo2, N Estrada2, L Romero2 1 Universidad Autonoma del Estado de Mexico, Toluca, Mexico; 2Instituto de Salud del Estado de Mexico, Toluca, Mexico Critical Care 2010, 14(Suppl 1):P475 (doi: 10.1186/cc8707) Introduction The main objective of this study is to show the experience of using telepresence with robots in acute care facilities (ACFs) at community hospitals (CHs) during an inluenza AH1N1 outbreak in Mexico. Methods Three CHs with 60 beds each were equipped with a telepresence system that includes: high-speed connectivity, wireless Internet access, a RP-7i robot (InTouch Health, Santa Barbara, CA, USA) and a central computer based at a high-care hospital. The CHs give medical care to people without social security and are far away from the capital city at not less than 63 km (Atlacomulco 63 km, Valle de Bravo 85 km and Tejupilco 90 km). The program was designated to assist physicians in ACFs, P476 Association between out of hours discharge from the ICU and subsequent readmission S Gopal, L Terry, C Corbett Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK Critical Care 2010, 14(Suppl 1):P476 (doi: 10.1186/cc8708) Introduction Readmission to the ICU may be considered a benchmark quality indicator on an ICU. Previous studies have assessed the impact of out of hours discharge from the ICU and subsequent outcome [1,2]. We hypothesized that patients who were discharged from the ICU after hours were at higher risk of readmission to the ICU than patients discharged during daylight hours. Methods The database of a 15-bed medico-surgical ICU of a teaching hospital was retrospectively interrogated from the period 1 October 2007 to 31 July 2009. Patients who died whilst on the ICU were excluded from the study. Demographic details were collected as well as the date and time of discharge from the ICU. Readmissions to the ICU were deined as readmissions if they occurred during the same hospital admission episode. Out of hours discharges were deined as discharges occurring between the hours of 20:00 and 09:00. Logistic regression analysis was Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S160 used to assess the relationship between timing of discharge from the ICU and risk of readmission. Results The database contained 1,257 patients during the study period, of whom 207 died whilst on the ICU. A total of 1,050 patients were therefore included in the study. Two hundred and forty-nine patients (24%) were discharged between 20:00 and 09:00. Ninety-ive patients (9%) were discharged and subsequently readmitted to the ICU during the same hospital admission episode. Compared with patients discharged between the hours of 09:00 and 20:00, patients discharged between the hours of 20:00 and 09:00 were 2.74 (95% CI 1.7 to 4.3) times more likely to be readmitted to the ICU during the same admission episode, P <0.001. This relationship remained true even after adjusting for potential confounders age, gender. OR 2.75 (95% CI 1.7 to 4.3). Conclusions Compared with patients discharged during the day, patients discharged during the night are at a signiicantly increased risk of readmission to the ICU. Timing of discharge from ICU may therefore be used as a quality indicator in benchmarking quality of care on an ICU. References Conclusions A SOFA score >11 was not associated with a hospital mortality >90% at any time during the ICU stay. Age and diagnostic category represent potential modifying factors in the association of SOFA >11 and hospital mortality. Only a small proportion of patients have the extreme initial SOFA values associated with a hospital mortality >90%, limiting the usefulness of SOFA as a triage instrument for pandemic planning. Reference 1. Introduction The complex interhospital transport of critically ill patients bears multiple risks for patient safety, including handovers and reliance on mobile medical equipment. The hypothesis of the present study was that multiple handovers of both equipment and patients in critical care transport would demonstrate omissions and a failure mode and efect analysis (FMEA) would unravel its safety priorities. Methods FMEA of the process of interhospital ground critical care transport in the Amsterdam region was performed by three clinical experts to estimate failures in handovers of patients and equipment. Deviations of the optimal process were documented by observations of 16 transports. A questionnaire was used to evaluate the multiple handovers of these transports by the escorting critical care registered nurses and intensivists and included attitude evaluation towards future structured checklists. Results The FMEA revealed that the highest risk priority numbers (above 45) were all related to the medical equipment control before start of transport. During transport observations the most frequent deviations in the process were related to omission of the deibrillator equipment check before transport (in nine out of 16 transports, 56%), handover of medication dose (25 of 39 syringe pumps, 64%) and location of infusion lines (39 of 54 lines, 72%). Nurses and intensivists demonstrated a positive attitude towards implementing handover checklists to improve the quality of the transport (29 of 34 respondents, 85%). Conclusions FMEA seems an applicable tool for risk assessment in critical care. The safety of interhospital critical care transport seems to be suboptimal by lack of standardized handovers. The check of medical equipment should have the highest priority in the optimization of safety in critical care transport. Handovers of information in critical care transport could possibly beneit from checklists. 2. Priestap FA, Martin CM: Impact of ICU discharge time on patient outcome. Crit Care Med 2006, 34:2946-2951. Hahane T, Keegan MT, Seferian EG, Gajic O, Afessa B: The association between nighttime transfer from the intensive care unit and patient outcome. Crit Care Med 2008, 36:2232-2237. P477 Sequential Organ Failure Assessment in pandemic planning R Shahpori, T Stelfox, C Doig, P Boiteau, D Zygun Alberta Health Services, Calgary, Canada Critical Care 2010, 14(Suppl 1):P477 (doi: 10.1186/cc8709) Introduction The H1N1 pandemic has highlighted the importance of reliable and valid triage instruments for scarce resources during periods of high demand. Christian and colleagues have proposed a triage protocol that utilizes a Sequential Organ Failure Assessment (SOFA) score >11 to exclude patients from critical care resources quoting an associated mortality of more than 90% [1]. We sought to assess the hospital mortality associated with this SOFA threshold and the resource implications of such a triage protocol. Methods This retrospective cohort study included consecutive ICU patients admitted to any one of our three tertiary-care adult multisystem ICUs from January 2003 to December 2008. Patients were excluded if they were admitted for routine postoperative monitoring (ICU stay <48 hours) or postoperative cardiac surgery. SOFA was collected daily by an electronic bedside clinical information system (QS; GE Medical Systems). Results A total of 10,204 patients (69,913 patient-days) were included. Mean age was 59. Mean admission APACHE was 19.1. Mortality was 25%. Median ICU LOS was 4 days. A total 13.4% of the cohort (representing 9% of total patient-days) had an initial SOFA >11. Mortality in patients with an initial SOFA score >11 was 59% (95% CI 56%, 62%). Figure 1 demonstrates increased mortality associated with SOFA >11 during the ICU stay to a maximum of 78% (95% CI 68%, 86%) on day 14. The mortality associated with an initial SOFA >11 across diagnostic categories (ICNARC) varied from 29% for poisoning to 67% for neurological patients. Mortality associated with an initial SOFA >11 was lowest for those patients 18 to 20 years old (37%) and highest for those >80 years old (75%). Mortality exceeded 90% when the initial SOFA was >20. However, only 0.2% of patients had an initial SOFA >20. Figure 1 (abstract P477). Hospital mortality associated with SOFA >11 during the ICU stay. 1. Christian et al.: CMAJ 2006, 175:1377-1381. P478 Failure mode and efect analysis in interhospital transport of critically ill patients: a tool to design checklists for handovers in the mobile intensive care unit E Van Lieshout, A Hamming, D Dongelmans, S Smorenburg Academic Medical Center, Amsterdam, the Netherlands Critical Care 2010, 14(Suppl 1):P478 (doi: 10.1186/cc8710) P479 Selective neurogenic blockades and perioperative immune reactivity in patients undergoing lung resection E Viviano1, M Renius1, J Rückert1, A Bloch1, C Meisel1, A Harbeck-Seu1, W Boemke1, M Hensel2, K Wernecke1,3, C Spies1 1 Charité-University Medicine Berlin, Germany; 2Parkklinik Weissensee, Berlin, Germany; 3Sostana GmbH, Berlin, Germany Critical Care 2010, 14(Suppl 1):P479 (doi: 10.1186/cc8711) Introduction Pain is the most relevant factor for prolonged hospital stay after thoracic surgery and is associated with stress known to alter the Th1/Th2 ratio (Th = T helper cells) in the immediate postoperative period. Thoracic epidural block (TEB), central α2-receptor stimulation via intravenous clonidine application and stimulation of opioid receptors can decrease either pain and/or stress and might therefore inluence this immune imbalance. The primary endpoint of the current study was the perioperative Th1/Th2 balance in lung surgery. The secondary endpoints aimed to the incidence of pain and pneumonia. Methods After approval by the ethics committee and informed consent a total of 60 patients was randomized to receive double-blinded either remifentanil intravenously, or remifentanil + clonidine intravenously, or ropivacaine epidurally. Pain intensity was assessed by the numeric rating scale (NRS). The Th1/Th2 ratio was measured using a cytometric bead Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 array. Pneumonia was diagnosed according to the hospital-acquired pneumonia criteria of the American Thoracic Society. Results The Th1/Th2 ratio adjusted for baseline difered between groups over time (P = 0.012). At the end of surgery there was no signiicant diference between the remifentanil and the remifentanil + clonidine groups (P = 0.679) but a signiicantly lower ratio in the ropivacaine group compared with the remifentanil (P = 0.004) and the remifentanil + clonidine groups (P = 0.019). NRS scores immediately after surgery were lower in the ropivacaine group compared with the remifentanil group and the remifentanil + clonidine group but achieved only borderline statistical signiicance. None of the patients developed pneumonia. Conclusions Intraoperative TEB decreases the Th1/Th2 ratio and provides better pain therapy immediately after surgery. P480 Adverse efects of beta adrenergic blockers during spinal anesthesia with 0.5% bupivacaine J Vukelić, M Rakarić Poznanović University Hospital of Traumatology Zagreb, Croatia Critical Care 2010, 14(Suppl 1):P480 (doi: 10.1186/cc8712) Introduction Protocol for perioperative usage of beta blockers was used in only 9% of major clinics in the USA. It is a very common practice to discontinue beta blockers during the perioperative period or to maximally reduce their doses. The main purpose of this paper is to investigate the incidence of adverse efects of beta blockers during large-scale trauma and orthopedic surgeries in spinal anesthesia. Methods In this open prospective study we evaluated the adverse efects of beta blockers in ASA II and III research subjects who received beta blockers 1 to 12 hours preoperatively, n = 37, mean age 67 ± 12, with adjacent metabolic syndrome. Results were compared with the same number of patients and ASA group, mean age 57 ± 18, who have not received beta blockers. Patients from both groups received midazolam premedication 30 minutes before arriving in the operating room and spinal anesthesia with 0.5% bupivacaine. Patient surveillance was conducted by continued EKG, blood pressure, pulse (all non-invasive) and SpO2 monitoring. Systolic and diastolic pressure and pulse were recorded every 10 minutes. Results were statistically tested (M ± SD, t test). Results The results are shown in Figure 1. The group receiving beta blockers shows a higher percentage of patients with hypertension on arrival in the operating room for 11% and hypotension after the start of spinal anesthesia. Occurrence of bradycardia (HR <60/minute) was increased with statistical signiicance for 24% (P <0.05), with use of atropine for 27% (P <0.05). The occurrence of arrhythmias shows a statistical increase in the same group, for 27% (P <0.05), as well as nausea for 29% (P <0.05). Conclusions Due to their adverse efects, beta blockers should be discontinued before spinal anesthesia and surgical procedures with signiicant circulating volume loss. References 1. 2. Mangano DT, et al.: N Engl J Med 1996, 335:1713-1720. Priebe JH: Yearbook of Intensive Care and Emergency Medicine; 2008:101-110. Figure 1 (abstract P480). Adverse beta blocker efects. 1. Preoperative hypertension. 2. Intraoperative hypotension. 3. Intraoperative bradycardia. 4. Arrhythmia. 5. Nausea. 6. Atropine applied. 7. Ephedrine applied. S161 P481 Remifentanil for postoperative analgo-sedation: efects on glycaemia and HOMA score C Chelazzi1, G Consales2, L Margiacchi1, AR De Gaudio1 1 University of Florence, Italy; 2Az USL 4, Prato, Italy Critical Care 2010, 14(Suppl 1):P481 (doi: 10.1186/cc8713) Introduction Surgical-related neuroendocrine stress response extends over the postoperative period, inducing insulin resistance and hyperglycaemia [1]. Remifentanil continuous infusion, reducing pain and anxiety, may reduce postoperative insulin resistance and result in better glycaemic control. The aim of the study was to assess trends in glycaemia and HOMA scores in postoperative patients during remifentanil-driven, postoperative analgo-sedation. Methods Enrolled patients were those consecutively admitted to a surgical ICU after major abdominal interventions during a 1-month period (July 2009). Group R patients underwent analgo-sedation with continuous remifentanil infusion at the recommended doses [2]. Glycaemia and HOMA scores were evaluated at admission time (T0) and after 12 and 24 hours. Control patients were those who underwent morphine-based continuous analgo-sedation (M Group). Diferences in glycaemias and HOMA scores across the two groups were tested with a Student t test (P <0.05). Results The total number of enrolled patients was 100. No diferences were found across the groups regarding general and clinical data, particularly age, prevalence of diabetes, and VAS and Ramsay scores during analgosedation. No diferences were found in glycaemia at T0 and T12, while at T24 the R group patients showed lower glycaemia than controls (99.4 ± 24.7 vs 104.2 ± 17.4 mg/dl, respectively; P = 0.018). No diferences either could be found in HOMA scores at T0 and T12, while at T24 the R group patients had lower scores than control patients (1.962 ± 0.19 vs 2.414 ± 0.81, respectively; P = 0.019). Conclusions Remifentanil-based analgo-sedation was associated with lower glycaemia and HOMA score in patients following major abdominal surgery, particularly at 24 hours from ICU admission. HOMA scores showed that morphine-treated patients were insulin resistant, although normoglycaemic. A better control of the neuroendocrine stress response in patients analgo-sedated with remifentanil might explain these results. References 1. 2. Langouche L: The dynamic neuroendocrine response to critical illness. Endocrinol Metab 2006, 35:777-791. Willhelm W: The place for short-acting opioids: special emphasis on remifentanil. Crit Care 2008, 12:S5. P482 Adding ultralow-dose oral naltrexone to morphine: a double-blind, randomized clinical trial S Farahmand1, O Ahmadi2 1 Tehran University of Medical Sciences, Tehran, Iran; 2Esfahan University of Medical Sciences, Esfahan, Iran Critical Care 2010, 14(Suppl 1):P482 (doi: 10.1186/cc8714) Introduction Ultralow-dose opioid antagonists can enhance opioid analgesia and prevent tolerance in rodent nociceptive pain assays. Methods A randomized, double-blind controlled trial is designed to investigate whether the addition of 5 ml ultralow-dose naltrexone (1 μg in a liter of sterile water) to morphine (0.05 mg/kg) changes the total opioid requirement and side efects. Results Two hundred and sixty-seven patients (18 to 45 years old) with moderate extremities trauma entered the study, Pain control measurements were evaluated every 15 minutes for the irst hour, then every 30 minutes for the second and third hours and inally at the fourth hour. Eicacy was measured by the 11-point numerical pain rating scale. The following side efects were evaluated: sedation, nausea, vomiting and pruritus. We found that opioid requirements did not difer signiicantly between groups. The morphine + naltrexone group on average required 0.04 mg more morphine during the 4 hours than the morphine group. Conclusions The morphine + naltrexone group had a lower incidence of nausea than the morphine + placebo group. However, the incidence of vomiting, pruritus and sedation between the two groups were similar. The combination of ultralow-dose naltrexone and morphine in moderate Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 extremities trauma did not afect opioid requirements, but it decreased the incidence of nausea. References 1. 2. Crain SM, Shen KF: Antagonists of excitatory opioid receptor functions enhance morphine’s analgesic potency and attenuate opioid tolerance/ dependence liability. Pain 2000, 84:121-131. Cepeda MS, Africano JM, Manrique AM, Fragoso W, Carr DB: The combination of low dose of naloxone and morphine in PCA does not decrease opioid requirements in the postoperative period. Pain 2002, 96:73-79. P483 Four-day sedation using sevolurane: luoride and renal function K Wagner, A Becker, T Meier, H Kehnscherper, HM Benad Klinikum Suedstadt Rostock, Germany Critical Care 2010, 14(Suppl 1):P483 (doi: 10.1186/cc8715) Introduction Volatile anesthetics for sedation in the ICU are currently undergoing a revival, mainly due to the recent availability of a novel delivery system, the anesthetic conserving device (ACD). Cytochrome P450 metabolic degradation of isolurane and sevolurane leads to the generation of inorganic luoride and hexaluoro isopropanol. Historically, data derived from methoxyluorane deined a luoride nephrotoxicity threshold of 50 μmol/l. Therefore, we investigated the feasibility and safety, focusing on kidney function, of 4-day sevolurane-ACD sedation. Methods Approval of the State Ethics Committee was obtained. Visceral surgical patients either received sedation via sevolurane-ACD (n = 20) or were intravenously sedated (sufentanil, propofol, n = 20). Serum luoride, renal, liver, pulmonary, cardiovascular function and depth of sedation were measured. Results Serum luoride concentrations increased signiicantly during sevolurane-ACD sedation (Figure 1). Renal function parameters and urinary output did not indicate deterioration of kidney function. Catecholamine support and pulmonary function were not diferent between the groups at equivalent depths of sedation. Conclusions Inhalational sevolurane sedation subsequently leads to a transient, marked increase of serum luoride concentrations. The methoxylurane luoride nephrotoxicity threshold was largely surpassed without apparent deleterious efect on renal volume regulation and detoxiication. The sedational use of the volatile anesthetic sevolurane up to 4 days is safe and feasible. Reference 1. Roehm et al.: Anesth Analg 2009, 108:1848-5184. S162 P484 Beneicial efect of sevolurane on endotoxin-induced pulmonary hypertension B Fyntanidou1, V Grosomanidis1, K Kotzampassi2, E Thomaidou1, G Mitos1, Z Aidoni1, C Skourtis1 1 Department of Anaesthesiology – ICU, and 2Department of Surgery, University of Thessaloniki Medical School, Thessaloniki, Greece Critical Care 2010, 14(Suppl 1):P484 (doi: 10.1186/cc8716) Introduction Pulmonary hypertension (PH) is a life-threatening disease commonly seen in ICU septic patients and associated with poor outcome. New and better therapies are required, since the response to various agents such as NO, prostaglandins and phosphodiesterase inhibitors is usually partial and the mortality rate remains high. Inhaled drugs seem to be an attractive treatment option, since they are delivered directly to pulmonary resistance vessels. A new device (anesthetic conserving device –AnaConDa (ACD)) permitting direct administration of volatile anaesthetics – such as sevolurane – to the breathing circuit of a conventional ICU ventilator in a safe and efective way has recently been introduced. The aim of the present study was to evaluate the eicacy and safety of sevolurane administration via the ACD on a porcine model of acute PH during sepsis. Methods PH was induced in 16 anaesthetized, mechanically ventilated swine (25 kg) by intravenous infusion of 0.5 mg/kg LPS (Escherichia coli, 111:B4) in a period of 30 minutes. After LPS, animals were randomized into two groups. In group A sevolurane was infused via the ACD, according to the manufacturer’s recommendations in order to obtain an end-tidal concentration of 0.5%, whereas group B did not receive sevolurane and served as control. Haemodynamic parameters (systemic and pulmonary) were recorded before (phase 0) and after the LPS (phase 1) and every 20 minutes for the next 2 hours (phases 2 to 7). Results LPS was found to produce PH (phase 1) and to reduce arterial blood pressure in both groups. After sevolurane infusion, both systolic (PAPs) and diastolic (PAPd) pulmonary pressures exhibited step-by-step reduction, which became statistically signiicant in phase 3 and thereafter, in relation to phase 1 values. On the contrary, in group B animals, not sevolurane-treated, pulmonary pressures remained at high levels throughout the study period. Systemic arterial pressure exhibited an endotoxin-related reduction in both groups, which was not found to be afected by sevolurane treatment. Conclusions Sevolurane administration via the ACD was found to reduce the pulmonary pressure in a porcine model of endotoxin-induced acute PH without any detrimental efects on the systemic circulation. This may represent a signiicant advance in the treatment of acute PH. However, the potential clinical implications of the method merit further study. P485 Does etomidate afect prognosis in septic shock patients treated with hydrocortisone? B Jung, N Clavieras, G Chanques, M Cisse, S Jaber Montpellier University Hospital, Montpellier, France Critical Care 2010, 14(Suppl 1):P485 (doi: 10.1186/cc8717) Figure 1 (abstract P483). Introduction Etomidate is well tolerated and not inferior to ketamine but because it is implicated in critical illness-related corticosteroid insuiciency (CIRCI) [1], its utilization in septic shock patients is controversial. In our ICU, the standard of care is to treat every septic shock patient with 200 mg hydrocortisone for at least 5 days. The aim of our study was to compare prognosis of septic shock patients intubated with etomidate with patients intubated without etomidate. Methods Observational study during a 2-year period including every septic shock patient. We compared the patients’ prognosis when intubated with etomidate (E group) to patients intubated without (NE group). We recorded demographic characteristics, results of a cosyntropin test, dose and length of vasopressors and hydrocortisone and outcome. The main endpoint was mortality in the ICU. The secondary endpoints were the length of shock, the dose of vasopressors and hydrocortisone in the ICU and the plasma cortisol level. Results We evaluated 62 patients in the E group and 31 in the NE group. Although SAPS II on admission was higher in the E group (54 (42 to 64) vs Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 45 (32 to 54)*), the total dose (95 mg (37 to 195) vs 66 mg (31 to 112)) and total duration (54 hours (36 to 91) vs 52 hours (31 to 81)) of vasopressors from day 0 to day 5 was not diferent between groups. However, the cosyntropin responder rate was higher in the non-E group (40% vs 18%*), hydrocortisone treatment duration (168 hours (78 to 216) vs 96 hours (72 to 144)*) and total dose of hydrocortisone (1,200 mg (500 to 1,625) vs 750 mg (350 to 1,125)*) was higher in the E group than in the non-E group. Finally, mortality in the ICU was not diferent between groups (32% vs 27% in the E and the non-E groups, respectively). *P <0.05. Conclusions In this study on septic shock treated with a short course of hydrocortisone, patients intubated with etomidate presented a CIRCI more frequently than patients intubated with another drug and needed a longer and higher dose of hydrocortisone treatment. However, length of shock, dose and duration of vasopressors and mortality were not diferent between groups. Etomidate-induced CIRCI when treated with hydrocortisone was not associated with a poorer outcome in our study. A comparison between etomidate and ketamine should be performed in this population. Reference 1. Jabre et al.: Lancet 2009, 374:293-300. P486 Use of methyl-naltrexone for the treatment of opioid-induced constipation in critical care patients SB Sawh1, A Danga1, IP Selveraj2, A Cotton1, PB Patel1 1 Imperial Healthcare NHS Trust, London, UK; 2Hillingdon Hospital NHS Trust, Hillingdon, UK Critical Care 2010, 14(Suppl 1):P486 (doi: 10.1186/cc8718) Introduction Methyl-naltrexone (Relistor®), a peripheral μ-opioid receptor antagonist shown to induce laxation in patients receiving opioids, is licenced for use in palliative care; a similar beneit is proposed in critical care patients. Impaired gut motility and constipation are common issues in the critical care setting with contributing factors including trauma, surgery and use of opiate analgesics. The efects of methyl-naltrexone were studied on seven patients in whom conventional treatment for constipation with stimulant and osmotic laxatives, faecal softeners and suppositories failed to produce efects. Methods Over a 6-week period, 15 critically ill patients with opiateinduced constipation (OIC) of more than 4 days duration were prospectively studied. All patients were treated with conventional methods from admission to critical care, which included regular senna and sodium docusate, supplemented with glycerin suppositories and picolax for resistant constipation. Methyl-naltrexone was administered to seven patients at 0.15 μg/kg subcutaneously on alternate days until laxation occurred. The remainder of patients in the study continued with conventional therapy. Results Six out of seven patients responded to methyl-naltrexone with laxation occurring between 12 and 24 hours. One patient did not respond due to faecal impaction but subsequently experienced laxation after manual disimpaction. Side efects were few (nausea 14%, vomiting 14%) and there was no increase in opiate requirement. Those patients treated by conventional means eventually produced laxation after a further 3 to 5 days. Conclusions Previous studies have shown the earlier return of gut motility improves patient progress, facilitates earlier respiratory weaning, prevents debilitation and results in reduced length of stay. Methyl-naltrexone is a safe and eicacious drug for the treatment of OIC in critical care patients in whom conventional treatments prove unsuccessful. Side efects are few and opiate requirements remain unchanged. Further investigation to elucidate the cost-efectiveness of methyl-naltrexone use in OIC of the critically ill patient is warranted. References 1. 2. 3. Artinian V, et al.: Chest 2006, 129:960-967. Mostafa SM, et al.: Br J Anaesth 2003, 91:815-819. Thomas J, et al.: N Engl J Med 2008, 358:2332-2343. S163 P487 Safety and eicacy of a nurse-driven sedation protocol with daily sedation interruption in the ICU KP Chan1, A Devanand1, CJ Chong2, JX Foo2, DP Ong1, PP Yap3, CM Loo1 1 Singapore General Hospital, Singapore; 2National University of Singapore, Singapore; 3Mount Elizabeth Hospital, Singapore Critical Care 2010, 14(Suppl 1):P487 (doi: 10.1186/cc8719) Introduction Sedation algorithms have been shown to reduce the duration of mechanical ventilation in the ICU. We evaluated the efect of the implementation of a nurse-driven sedation protocol with daily sedation interruption in our ICU. Methods We performed a before-and-after prospective study in our eightbed medical ICU over a 6-month period. All patients requiring mechanical ventilation and who were not receiving neuromuscular blocking agents were included. Prior to implementation, sedation was adjusted according to physician orders. During the intervention period, sedatives and analgesics were adjusted by nurses according to an algorithm utilizing the Sedation-Agitation Scale. Results We included a total of 188 patients, 89 patients in the observational period and 99 patients during the intervention period. The duration of mechanical ventilation was similar (2 days in both groups). However, the ICU length of stay (LOS) was reduced by a day after implementation (3 days vs 2 days). Amongst patients who survived and who were mechanically ventilated for more than 4 days, the duration of mechanical ventilation and ICU LOS were reduced (7 days vs 6 days and 8 days vs 6 days, respectively). Fewer CT brains were performed for persistent coma after discontinuation of sedation in the intervention period (4.5% vs 1.2%). Complications such as extubation failure, tracheostomy and inadvertent removal of devices were similar in both groups. Conclusions A nurse-driven sedation protocol is safe and may reduce duration of mechanical ventilation and ICU LOS, especially amongst patients who have been ventilated for more than 4 days. P488 Efects of propofol and midazolam on indocyanine green elimination assessed with LiMON for early sepsis patients M Kargı, D Memis, N Sut Trakya University, Edirne, Turkey Critical Care 2010, 14(Suppl 1):P488 (doi: 10.1186/cc8720) Introduction We aimed to select the sedative drug with the least impact on hepatic blood low in sedation-administered patients. In our study, we aimed to establish whether or not midazolam and propofol afect liver function during sepsis. The hepatic blood low is evaluated by the transcutaneous assessment of the indocyanine green plasma disappearance rate (ICG-PDR) in critically ill patients. Methods Forty sepsis patients were included in the study with either the loading dose infusion of propofol 1 mg/kg over 15 minutes followed by a maintenance 1 to 3 mg/kg/hour (n = 20, Group P) or a loading dose of midazolam 0.2 mg/kg over 10 minutes followed by a maintenance 0.04 to 0.06 mg/kg/hour (n = 20, Group M), 24 hours infusion. ICG elimination tests were conducted concurrently using the non-invasive liver function monitoring system (LiMON). A dose of 0.3 mg/kg ICG was given through a cubital fossa vein as a bolus and immediately lushed with 10 ml normal saline. We calculated ICG-PDR. The ICG-PDR measurements were obtained at baseline (before start of the propofol or midazolam infusion) and were repeated at 24 hours. Biochemical and hemodynamic parameters, ICGPDR were recorded before start of the study and at 24 hours. Results Biochemical and hemodynamic parameters did not difer signiicantly between the groups (P <0.05). Group P compared with Group M; baseline ICG-PDR levels (23.67 ± 12.02 vs 23.86 ± 11.4, respectively), and after the study ICG-PDR levels (26.04 ± 13.60 vs 24.07 ± 9.07) did not difer in groups (P >0.05). When we examined before and after ICG-PRD changes between groups, there was no signiicant diference (P >0.05). Conclusions In our study, we found that neither propofol nor midazolam infusion afected hepatic blood low. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P489 Assessment of correlation between Bispectral Index monitorization and sedation scales used in the intensive care unit F Yaman, N Ozcan, A Ozcan, C Kaymak, H Basar Ankara Training and Research Hospital, Ankara, Turkey Critical Care 2010, 14(Suppl 1):P489 (doi: 10.1186/cc8721) Introduction The level of sedation should be monitored as the depth of sedation can afect the rate of related complications, length of hospital stay and costs [1]. The recent study aims to monitor the depth of sedation of patients in the ICU using the Ramsay Sedation Scale (RSS), Richmond Agitation Sedation Scale (RASS), Sedation Agitation Scale (SAS) and Adaptation To Intensive Care Environment scale (ATICE) and to assess the correlation between these scales and Bispectral Index (BIS) scores and to compare the correlation coeicients of these scales with each other. Methods After approval from the hospital ethics committee, 30 mechanically ventilated patients who required sedation in the ICU were enrolled into the study. Patients who are quadriplegic or need muscle paralysis are excluded. The choice of sedative agent and the dose regimen that will be used are left to consultant ICU staf diferent from the investigators. Demographic data and APACHE II scores of the patients were registered. BIS, RSS, RASS, SAS, ATICE scores, mean arterial pressure, heart rate, and peripheral oxygen saturation values (SpO2) of the patients were registered before the initiation of the sedation and in 2-hour intervals after initiation of the sedation. Results Male/female ratio was 22/8, mean of ages and body weights of the patients were 57.3 ± 15.8 years and 69.6 ± 14.3 kg, respectively. The median of APACHE II scores was 14 (4 to 23). Mean arterial pressure, heart rate and SpO2 changes were insigniicant after initiation of sedation compared with the beginning (P >0.05). BIS, RASS, SAS scores were signiicantly lower, RSS scores were signiicantly higher in all intervals compared with the beginning (P <0.05). Signiicant change was not observed for ATICE scores compared with the beginning value (P >0.05). Statistically signiicant correlation was observed between all scoring systems and BIS values (P <0.05). Signiicantly highest correlation was found between BIS–RSS and BIS–RASS (r = 0.758 and r = 0.750, respectively), comparing correlation between BIS–SAS (r = 0.656) and BIS–ATICE (r = 0.565) (P <0.05). Also, correlation between BIS–SAS was signiicantly higher than BIS–ATICE correlation (P <0.05). Conclusions All scales assessed in this study showed signiicant correlation with BIS. The signiicantly highest correlation was found between BIS–RSS and BIS–RASS and lowest correlation between BIS–ATICE. References 1. Jacobi J, et al.: Crit Care Med 2002, 30:119-141. P490 Sedation and analgesia: early results from a web-based survey of UK practice C Mckenzie, S Yassin, M Terblanche Guy’s and St Thomas’ NHS Foundation Trust, London, UK Critical Care 2010, 14(Suppl 1):P490 (doi: 10.1186/cc8722) Introduction Evidence suggests prolonged sedation is associated with prolonged ventilation and mortality. Further evidence suggests that some sedatives and analgesics are more prone to cause oversedation than others, possibly due to disturbances in pharmacokinetic properties in the context of acute organ failure. Our aim was to describe current sedation and analgesic practice in UK ICUs, and to determine whether recent evidence has changed practice in recent years. Methods We performed a web-based survey using a tool developed via a systematic, step-wise process following recognised practice for questionnaire design. These steps included question development and questionnaire formatting and testing before being published on the Zoomerang™ website. The sampling frame was pharmacists who are members of the United Kingdom Clinical Pharmacy Association Critical Care Group (UKCPA CCG). Participants were invited to complete the 15-minute questionnaire. Email reminders were sent to all members every 2 weeks. After 6 months a reminder email was sent to pharmacists in institutions that had not responded. Questions were split into four S164 categories: pharmacist and ICU-speciic data; current sedation practice; sedative choice; and analgesic choice. Results The response rate was 68%. Eighty-four per cent of respondents were senior pharmacists and 54% provided a service within a team. The median number of annual ICU admissions was 750 (IQR 635 to 865) and included a wide-ranging case mix. Forty-nine per cent of ICUs had a sedation policy, of which 76% included sedation holds and 87% used a sedation scoring system. Forty-three per cent assessed for delirium, but only 29% used a known delirium scoring system. Ninety-nine of the respondents used propofol (PPF) in the majority of patients, 56 midazolam (MDZ). Twenty-seven still used MDZ routinely in renal or hepatic failure, while 75 used MDZ where sedation was challenging. Fifty-ive used morphine, 37 fentanyl and 33 alfentanil as irst-line opiate. Conclusions These data suggest that many ICUs do not routinely use sedation policies or assess patients for delirium. While PPF remains the irst-line sedative for most ventilated patients, MDZ and morphine are still widely used despite evidence of prolonged efects in the presence of hepatic and renal failure. References 1. McKenzie CA, et al.: Crit Care 2005, 9:32-36. P491 Severe alcohol withdrawal syndrome in ICU: is propofol a safe option? JI Chico1, C Rivero2, R Casado3, L Sayagues2, E Saborido4, E Sanmartin2, D Sander2, J Garcia-Allut2 1 Hospital Montecelo, Pontevedra, Spain; 2Hospital Clinico, Santiago Compostela, Spain; 3Hospital Lozano Blesa, Zaragoza, Spain; 4Hospital Montecelo, Pontevedra, Spain Critical Care 2010, 14(Suppl 1):P491 (doi: 10.1186/cc8723) Introduction This study aims to compare the eicacy of midazolam or propofol in severe refractory AWS, to detail characteristics of patients and to test the usefulness of diferent scores (MELD, Child, APACHE II) in severe AWS. Methods Patients admitted to the ICU during a 3-year period for refractory AWS after a failed treatment with benzodiazepines according to a symptom-triggered protocol in the general ward or emergency room were treated with neuroleptics and either midazolam or propofol infusion. Processes that could lead to a confounding delirium were excluded. We retrospectively analysed this cohort of patients. Results Fifty patients were reviewed, 85.7% men. Mean age was 49 years. Thirty percent had been previously admitted to the ICU for the same reason. Main reason for alcohol withdrawal was abdominal pain (12.2%). Mean alcohol ingestion was 150 g/day. Mean CHILD/MELD/APACHE score was 6/8.5/13 (24.5% patients had a Child score ≥7). Seventy-three percent of patients developed complications (especially respiratory infections in 19 patients). The most frequent agent found was MSSA and Gram-negative bacilli. Seizures accounted for 38% of patients and hepatic encephalopathy in two. We found no relationship between CHILD or MELD score and rate of intubation, length of stay or complications. Patients with APACHE II >12 at admission had a signiicant increase in risk of intubation (OR 31.2, P <0.001). Patients with more than 12 days of stay had a signiicant risk of intubation (OR 49.7, P <0.0001). Thirty-ive patients received propofol as the irst intravenous sedation and 14 midazolam. Only two patients with midazolam required a second intravenous sedation. Conversely, nine (26.47%) patients initially with propofol required a second sedation with midazolam. The propofol group showed a signiicant increase in incidence of seizures (41.17% vs 21% in midazolam group) and infections (47.1% vs 28%) independent of APACHE score. These indings were more remarkable in the subgroup that needed a second intravenous sedation (66% seizures and 77% infection rate). This group had higher APACHE score and was associated with a greater likelihood of intubation and a signiicant 2-day increase in length of stay. Conclusions Propofol has been proposed as an alternative to benzodiazepines in severe AWS, but it could increase the rate of complications (especially seizures and respiratory infections) that could lead to an increase in the intubation rate and length of stay. The APACHE score could be a predictor for the risk of complications and intubation. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P492 Agitation and pain during physiotherapy in intensive care K Everingham1, L Salisbury2, P Lapinlampi3, I Cornwall1, F Frame4, T Walsh1 1 NHS Lothian, Edinburgh, UK; 2University of Edinburgh, UK; 3GE Healthcare, Helsinki, Finland; 4University of Leicester, UK Critical Care 2010, 14(Suppl 1):P492 (doi: 10.1186/cc8724) Introduction The objective of this study was to identify the proportion of patients who experienced agitation and/or pain during physiotherapy sessions in intensive care (ICU). The prevalence and causes of distress in critically ill patients are poorly described. Identiied stressors include physiotherapy [1,2], but no standards for sedation/analgesia management during physiotherapy exist. Recent evidence supporting routine ICU management at lighter levels of sedation potentially increases the importance of interventions to avoid distress during interventions such as physiotherapy. Methods A prospective observational study was undertaken. Fortynine patients admitted to the ICU requiring mechanical ventilation and physiotherapy were recruited into the study. A single session of physiotherapy was observed by an independent assessor. Agitation was measured using the Richmond Agitation Sedation Scale (RASS) and pain using the Behavioural Pain Scale (BPS). The RASS and BPS were collected immediately pre physiotherapy, after each intervention during physiotherapy and at 5 and 30 minutes post physiotherapy. Results Sixteen participants (33%) experienced agitation (RASS score ≥1) while 48 participants (98%) experienced pain (BPS score ≥4). Figure 1 shows the number of participants who experienced agitation and pain in relation to their RASS level prior to physiotherapy. Of interest, the independent assessor observed little communication, in regards to the management of sedation or pain at any stage during physiotherapy, between nursing and physiotherapy staf. Figure 1 (abstract P492). Agitation and pain in relation to prephysiotherapy RASS scores. Conclusions Regardless of the RASS level pre physiotherapy, the majority of participants experienced pain. In contrast, only one-third of participants experienced agitation; this was more prevalent for those at a lighter sedation level. More routine use of RASS, BPS and communication with nursing staf should be undertaken during physiotherapy to ensure optimal levels of sedation and adequate levels of analgesia are achieved. References 1. 2. Novaes et al.: Intensive Care Med 1999, 25:1421-1426. van de Leur et al.: Crit Care 2004, 8:R467-R473. P493 Pain evaluation in the intensive care unit: listen to the patient, a new approach! G Chanques1, B Jung1, M Cissé1, S De Lattre1, E Viel2, S Jaber1 1 Saint Eloi – Montpellier University Hospital, Montpellier, France; 2Carémeau – Nimes University Hospital, Nimes, France Critical Care 2010, 14(Suppl 1):P493 (doi: 10.1186/cc8725) Introduction Contrary to wards that manage usually chronic or acute pain (algology, gerontology, surgery, recovery room, and so forth), a comparison of the ive most popular self-report pain tools (vertical and horizontal Visual Analog Scale (VAS-V, VAS-H), 0 to 10 oral Numeric Rating S165 Scale (NRS-O), 0 to 10 visual enlarged NRS (NRS-V), Verbal Descriptor Scale (VDS)) has never been evaluated in an ICU setting. Methods Consecutive patients admitted to a medical–surgical ICU during 1 year were included when alert (RASS >–2) and able to follow simple commands. Exclusion criteria: previous self-report pain assessment without the presence of an investigator. Pain assessment using the ive scales in random order either at baseline (T1) and after (T2) administration of an analgesic, or during a nociceptive procedure, in absence of pain at baseline. Evaluated parameters: psychometric properties of scales (feasibility, validity, responsiveness and preference). Nonparametric tests were used for statistical analysis (Statview 5.0). Data are expressed as median (25th to 75th). Results One hundred patients were included 24 (12 to 96) hours after their admission to the ICU: age 58 (48 to 69) years, SAPS II 39 (32 to 48), SOFA 7 (3 to 9), medical admission (49%), intubation before inclusion (76%), at time to inclusion (50%). At T1, 91% of patients were able to use at least one scale and 57% all ive scales. The NRS-V had the lowest failure rate (9%) compared with NRS-O (17%), VDS (22%), VAS-H (32%) and VAS-V (34%). Validity was measured in the 56 patients who were able to use the ive scales both at T1 and T2. The pain intensity measured with the ive scales changed signiicantly between T1 and T2 (P <0.01), showing a good discriminative validity. The correlation between the ive scales was important (Spearman’s coeicients ranged from 0.75 to 0.96, P <0.001). The responsiveness was very good for each of the ive scales, either after an analgesia and a nociceptive procedure (efect size >0.8). Finally, the NRS-V was considered respectively by 45, 37 and 44% of patients as the easiest, most accurate and preferred scale. The preference for the other scales was <12%. Conclusions The self-report of pain is feasible in ICU patients as soon as they are suiciently alert (RASS >–2) and able to follow simple commands. The enlarged 0 to 10 Numeric Rating Scale is the easiest scale to use with the lowest failure rate and it is the preferred scale for the majority of critically ill patients who were able to communicate. P494 Pharmacokinetics of orally administered melatonin in critically ill patients B Moroni1, G Mistraletti1, RJ Reiter2, R Esposti1, E D’Angelo1, P Formenti1, D Palmisano1, E Borotto1, P Di Mauro1, G Iapichino1 1 Università degli Studi di Milano, Milan, Italy; 2University of Texas Health Science Center, San Antonio, TX, USA Critical Care 2010, 14(Suppl 1):P494 (doi: 10.1186/cc8726) Introduction Critically ill patients exhibit reduced melatonin secretion, both in nocturnal peaks and basal daytime levels. Oral melatonin supplementation may be useful for known sedative and antioxidant properties. Methods Melatonin early enteral absorption and daily pharmacokinetics were determined in two cohorts of six high-risk patients in this prospective trial. During their third and fourth ICU day, they underwent two diferent sets of repeated blood samples to detect serum melatonin levels through radio-immunoassay. Cohort 1: samples taken at 20:00, 20:45, 21:30, 24:00, 03:00, 06:00, 14:00, 20:00 to describe the daily pharmacokinetics. Cohort 2: 20:00, 20:05, 20:10, 20:20, 20:30, 20:45 to study the early absorption. On ICU day 3, endogenous levels were measured, while the absorption of exogenous melatonin was determined on ICU day 4 after administration, at 20:00, of 3 mg melatonin. Results All basal levels were below the expected values. Following enteral administration, pharmacological levels were already reached in 5 minutes, with a serum peak after 16 minutes (half-absorption time: 3 minutes 17 seconds). The maximum serum level observed was 11,040 pg/ml and the disappearance rate indicated a half-elimination time of 1 hour 34 minutes. Serum melatonin levels decreased signiicantly after midnight; pharmacological levels were maintained up to 10 hours following administration. No excessive sleepiness was reported in this patient group. Conclusions Critically ill patients exhibited reduced melatonin secretion, as reported in the literature. Despite the critical illness, the oral bioavailability was satisfactory: serum levels after oral administration showed basically unchanged intestinal absorption, while the disappearance rate was slower than reported elsewhere in healthy volunteers. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P495 Manifestations and clinical course of delirium tremens in the ICU JA Camacho Oviedo, C Soriano Cuesta, J Manzanares Gomez, L Cachafeiro Fuciños, M Oliveros Fonseca, R Garcia Hernandez, M Jimenez Lendinez Hospital Universitario la Paz, Madrid, Spain Critical Care 2010, 14(Suppl 1):P495 (doi: 10.1186/cc8727) Introduction The aim of our study is to describe clinical progress, need for mechanical ventilation (MV), complications and mortality of patients with delirium tremens (DT) admitted to our ICU. Methods Patients with a diagnosis of DT admitted to a medical ICU of a tertiary hospital from January 2001 to December 2008 were included. We recorded: admission diagnosis, pathologies associated with DT, APACHE II score, treatment, need for MV and duration, complications, length of stay in the ICU and total hospital stay, mortality and survival at 2 years. Results There were 50 cases of DT. Median age 45 years, 96% male. Reasons for hospital admission: DT (68%), seizures (36%), sepsis (16%), brain injury (10%). Reasons for admission to the ICU: DT (54%), DT and seizures (26%), DT and brain injury (10%), DT and sepsis (8%), DT and other (2%). Median APACHE II score was 9 (range: 8 to 13). Seventy-four percent of the patients were controlled with no need for MV with a midazolam infusion of 45 to 50 μg/kg/hour and haloperidol of 17 to 30 μg/kg/hour. Twenty-eight per cent (14 patients) required MV, of them 78% had DT and other associated pathology on admission (Figure 1). From a total of 28 patients admitted with DT and no associated pathology, only four needed MV. The median time on MV was 2 days (range: 1 to 9). Complications were present in 22%: ventilation-associated pneumonia, and other infectious conditions. Total hospital length of stay 14 days ((SD: 11), 5.5 days in the ICU (SD: 9). The registered hospital mortality was 4%. Rate of survival at 2 years was 84%, from these 72% had continuous visits to emergency (≥5 consultations in 2 years) for episodes related to alcohol withdrawal or complications associated with chronic alcohol abuse. S166 cognitive impairment in survivors [1,2]. The two most commonly used validated assessment methods for diagnosing delirium in intensive care are the Confusion Assessment Method for ICU (CAM) and the Intensive Care Delirium Checklist Score (ISDCS) [3]. We wished to determine the prevalence of delirium in our unit, whether there was a diference in results between these methods of assessment and whether good agreement could be achieved between two trained assessors. Methods We performed a prospective prevalence study in a single tertiary ICU. Patients were assessed between days 3 and 10 of their stay and tested provided their Richmond Agitation Sedation Score (RASS) was ≥–3 [1]. Each patient was independently assessed by the two trained assessors with the CAM and ISDCS, with randomisation of both the order of interview and the score used. Both sets of assessments were carried out within an hour of each other. Exclusions included readmissions, those who did not speak English, the deaf and registered psychiatric patients. The CAM was completed by the assessors and the ISDCS required observational answers from the bedside nurse. Results We performed 104 assessments (208 tests) on 52 patients. Mean (SD) age, APACHE II and total SOFA on the day of admission were 67.4 (14.0), 14.0 (5.3) and 5.7 (2.7), respectively. Delirium was found in 37.5% of patients using the CAM, but only 14.4% using ISDCS. Inter-rater agreement for CAM and ISDCS was 86.5% (κ 71.4%, SE 13.8%, P <0.001) and 94.2% (κ 76.7%, SE 13.8%, P <0.0001), respectively. There was signiicant underscoring of the RASS by the bedside nurses. When the trained assessors found a diference, it was always lower than the score documented by the bedside nurse. Conclusions There was good inter-rater agreement in the diagnosis of delirium between the two trained assessors, but the prevalence found was lower than previously reported [1] and varied considerably with the method used. The diference in results between the two scores may be due to a lack of discernment on the part of the bedside nurse of the ISDCS assessment process. References 1. 2. 3. Ely et al.: Crit Care Med 2001, 29:1370-1379. McNicoll et al.: J Am Geriatr Soc 2003, 51:591-598. Delvin et al.: Crit Care 2008, 12:1. P497 Quetiapine in prolonged ICU delirium MR Kasliwal, C McKenzie, NA Barrett Guy’s and St Thomas’ NHS Foundation Trust, London, UK Critical Care 2010, 14(Suppl 1):P497 (doi: 10.1186/cc8729) Figure 1 (abstract P495). Use of MV in patients admitted for DT. Conclusions Even though our patients with DT are frequently admitted to the ICU, this is a pathology that most of the time has a benign course with low hospital mortality and high rate of survival at 2 years. These patients are regular users of the health system. The occurrence of complications and the need for MV in our patients were low, and were present in the group of DT with other diagnoses. Introduction Delirium afects up to 33% of acutely hospitalized patients. In ICU patients it can prolong the length of stay and increase mortality [1]. The optimal management of delirium requires a calm environment, sleep hygiene and correction of underlying factors (for example, infection). This can be a challenge in the ICU, and drug therapy, commonly haloperidol, clonidine, benzodiazepines or propofol, is often used [1]. Quetiapine, an atypical antipsychotic, has been used in acute delirium outside the ICU [2]. It has few extrapyramidal side efects, a short half-life and is mildly sedating. Our impression was that it had potential in the treatment of delirium. Methods In a 30-bed tertiary ICU with more than 1,200 admissions annually we reviewed the notes of patients admitted from February 2008 to November 2009 who had a delirium treated with quetiapine. Patients were excluded if they were taking quetiapine prior to admission. The following data were recorded: Richmond Agitation and Sedation Score Table 1 (abstract P497) P496 Comparison of two methods for diagnosing delirium conducted in a mixed medical ICU and the concordance between two independent nurse assessors S Heuer, J Nicholls, M Terblanche, D Treacher Guy’s and St Thomas’ NHS Foundation Trust, London, UK Critical Care 2010, 14(Suppl 1):P496 (doi: 10.1186/cc8728) Introduction Delirium in ICU patients increases time on mechanical ventilation, is an independent risk factor for death and can cause Patient RASSpre (D) Q dose (mg) RASSpost (d) 1 +1 (22) 12.5 OD 0 (5) 2 +3 (21) 50 BD 0 (5) 3 +4 (31) 12.5 BD 0 (3) 4 +4 (28) 12.5 BD 0 (5) 5 +3 (36) 25 BD 0 (6) (D), days delirium present; Q, quetiapine; (d), days to achieve the RASS. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 (RASS), duration of delirium, agents used, patient demographics and adverse events. Results Five patients met the inclusion criteria (Table 1). All were males, aged 37 to 85 years. All had a prolonged delirium prior to the commencement of quetiapine and all were on a combination of four drugs (clonidine, haloperidol, lorazepam and propofol) that were not controlling their delirium. At 3 to 7 days following commencement of quetiapine the RASS scores were 0 and other drugs were ceased. No adverse efects were noted. Conclusions Quetiapine was successful in controlling prolonged ICU delirium and allowed weaning of other medications in these patients. It may be a useful delirium therapy. Further studies are required to demonstrate eicacy and safety. References 1. 2. Ely, et al.: JAMA 2004, 291:1753-1762. Schwartz, et al.: Prim Care Companion J Clin Psychiatry 2000, 2:10-12. P498 PREDICT, Prediction of Delirium in ICU Patients: development and validation of a prediction model M Van den Boogaard, P Pickkers, H Van der Hoeven, R Donders, T Van Achterberg, L Schoonhoven Radboud University Medical Centre Nijmegen, the Netherlands Critical Care 2010, 14(Suppl 1):P498 (doi: 10.1186/cc8730) Introduction Delirium is a serious and frequent disorder in the ICU, but a prediction model for critically ill patients is lacking. Methods We performed two prospective cohort studies in a 33-bed ICU for adult patients with use of the validated CAM-ICU, performed three times daily by well-trained ICU nurses. Twenty-three identiied delirium risk factors were collected within 24 hours after admission and patients were followed during their ICU stay until death, discharge or development of delirium. Variables with P >0.1 in univariate logistic regression, or with a prevalence rate <10% were excluded. Multivariate logistic regression analysis was followed by bootstrapping. Reduced coeicients were used on the second cohort for external validation. Also, nurses and physicians were asked to predict whether the patient would develop delirium during the ICU stay. Results In the irst study (February 2008 to February 2009) 2,116 consecutive patients and in the second study (May to September 2009) 748 patients were screened, of which 503 and 199 patients, respectively, were excluded for valid reasons. Ninety per cent of the total number of assessments that should have been performed was actually obtained and the Cohen’s kappa for inter-rater reliability was 0.90. Out of 1,613 patients, 411 developed delirium and in the second study 171 out of 549 patients. Eight risk factors were excluded because of a prevalence rate <10% and one because of P >0.1. After multivariate logistic regression analysis, 10 risk factors were included in the prediction model (age, APACHE II score, coma, diagnose group, increased urea, infection, metabolic acidosis, morphine use, sedation use, emergency admission) of which the area under the receiver-operation characteristic curve (AUC) was 0.87 (95% CI 0.85 to 0.89) and after bootstrapping 0.86. The cut-of point with the optimal predicted probability lies at 0.196 points. At this cut-of the sensitivity of the prediction rule is 80% and the speciicity is 79%. Validation of PREDICT on the second cohort resulted in an AUC of 0.89 (95% CI 0.86 to 0.92). The AUC of the prediction of nurses and physicians was signiicantly lower, both 0.59 (95% CI 0.49 to 0.70). Conclusions We have developed and validated a delirium prediction model (PREDICT) with a high AUC that can be used in all adult ICU patients within 24 hours after ICU admission to predict the chance of delirium during their ICU stay and to guide preventive interventions. P499 Hospital anxiety depression scale in our surgical ICU IF Filipovic-Grcic, DT Tonkovic, JG Grubisin, MP Peric, VM Majeric Kogler University Clinical Hospital Center Zagreb, Croatia Critical Care 2010, 14(Suppl 1):P499 (doi: 10.1186/cc8731) Introduction All patients in the ICU go through mental, physical and emotional adjustment. They can experience exaggerated symptoms S167 of anxiety and depression and it can delay their recovery [1]. Stress has a major role and there are so many triggers for it: the psychological and physical condition, surgery, pain, ICU environment and so forth. The aim of this study was to implement the Hospital Anxiety Depression Scale (HADS) in our everyday ICU practice and then to analyze the impact of the clinical picture (APACHE II score) and pain control (VAPS – visual analog pain scale) on the anxiety and depression symptoms (HADS) in surgical ICU patients. Methods With ethics approval and written consent, in this prospective study, to date are reported 70 patients. They all underwent major abdominal surgery and were discharged from the ICU after 24 to 30 hours. Patients with any mental disorder or neurological disease were excluded. On admission and discharge the VAPS, APACHE II and HADS were evaluated. HADS was evaluated again 1 month later (62 of 70 patients). Anxiety and depression are assessed as separate components, each with seven items that are rated from 0 to 3 [2]. A score <7 in a component is a normal result, 8 to 10 indicates mild symptoms, 11 to 14 moderate symptoms and 15 or more indicates severe symptoms [2]. The Mann–Whitney U test, t test and correlations were used in statistical analysis. Results Average age of the patients was 58.61 ± 13.56, range 24 to 78, 37 male and 33 female. Average values on admission were: VAPS 3.02 ± 0.50, APACHE II 10.31 ± 2.79, Anxiety 4.82 ± 4.01, Depression 3.91 ± 3.23, and on discharge were: VAPS 1.34 ± 0.88, APACHE II 5.25 ± 2.78, Anxiety 3.41 ± 2.97, Depression 3.71 ± 2.97. One month later the values were: Anxiety 3.14 ± 2.79, Depression 1.27 ± 0.57. Patients with lower pain control had more exaggerated symptoms of anxiety and depression. After 1 month, seven patients had mild symptoms of anxiety, nine patients had mild symptoms of depression and four patients had moderate symptoms of depression. Conclusions HADS has its role in everyday ICU practice. All patients with mild to severe symptoms of anxiety or depression should be further psychologically evaluated. There is a need to evaluate in our ICU the patients who are staying there a few days or more and compare it with the results of this study. References 1. 2. Sukantarat et al.: Anaesthesia 2007, 62:239-243. Zigmond et al.: Acta Psych Scand 1983, 67:361-370. P500 Fluid therapy change from synthetic colloids to only crystalloids in patients with severe sepsis O Bayer, Y Sakr, B Kabisch, CS Hartog, N Riedemann, U Settmacher, K Reinhart Friedrich-Schiller-University Jena, Germany Critical Care 2010, 14(Suppl 1):P500 (doi: 10.1186/cc8732) Introduction After changing the standard resuscitation colloid on our ICU from 6% HES 130/0.4 to 4% gelatin, we found that both HES 130/0.4 and gelatin resulted in a high incidence of renal failure (43.2% and 40.2%) in patients with severe sepsis [1]. We therefore changed from synthetic colloids to only crystalloids and herewith report on the efects. Methods Before–after retrospective study in patients with severe sepsis on a surgical ICU. The synthetic colloids group (SynColl-Group) comprised patients who received either predominantly 6% HES 130 or predominantly gelatin between January 2005 and June 2006. The crystalloid group (CrysGroup) comprised patients from September 2008 to June 2009 who received only crystalloids. Acute renal failure (ARF) was deined as new need for renal replacement therapy (RRT) or at least a twofold increase in baseline creatinine. Results Two hundred and ive patients received synthetic colloids, and 141 received only crystalloids. There were minor baseline diferences but SAPS II and SOFA scores, age and creatinine were similar at admission. Fluid therapy (median cumulative doses): patients in the SynCollGroup received 4 l (IQR 2 to 8.3 l) colloids and 27.9 l (IQR 15.7 to 48.3 l) crystalloids. Patients in the Crys-Group received only 25.0 l (IQR 13.1 to 52.2 l) crystalloids. Crystalloid volumes did not difer signiicantly between groups (P = 0.605). Median cumulative dose of HES was 50 ml/kg and of gelatin was 43.3 ml/kg. Outcomes: patients in the SynColl-group had a higher incidence of ARF (41.0% vs 23.4%, P = 0.001) and increased need for RRT (35.1% vs 22.0%, P = 0.009). ICU mortality and hospital mortality did not difer between SynColl and Crys groups (31.2% vs 30.5% and 38% Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 vs 36.9%, respectively). The ICU length of stay tended to be longer in the SynColl-Group (14 versus 10 days, P = 0.055). Conclusions In patients with severe sepsis, luid therapy with synthetic colloids – gelatin or the third-generation 6% HES 130/0.4 –considerably increases the incidence of ARF and need for RRT compared with crystalloids. These results conirm recent meta-analysis and RCTs, which demonstrated an increased incidence of ARF by synthetic colloids [2,3]. References 1. 2. 3. Schabinski et al.: Intensive Care Med 2009, 35:1539-1547. Zarychanski et al.: Open Med 2009, 3:E196-E209. Brunkhorst et al.: N Engl J Med 2008, 358:125-139. P501 Efects of balanced and unbalanced colloid and crystalloid solutions on renal microvascular perfusion in endotoxemic rats U Aksu1, C Demirci-Tansel2, C Ince1 1 University of Amsterdam, the Netherlands; 2Istanbul University, Istanbul, Turkey Critical Care 2010, 14(Suppl 1):P501 (doi: 10.1186/cc8733) Introduction In this study we investigated the efects on renal microcirculatory perfusion of resuscitation with hydroxyethyl starch (HES 130/0.42) dissolved in a balanced Ringer’s acetate salt solution (Plasma Volume Redibag®, HES-RA) or hydroxyethyl starch (HES 130/0.4) dissolved in saline (Voluven®, HES-NaCl) and compared this with resuscitation with saline solution (0.9% NaCl, NaCl) in an LPS-induced septic shock model in the rat. Methods In 20 anesthetized, mechanically ventilated rats, endotoxic shock was induced by infusion of LPS (10 mg/kg over 30 minutes). When the mean arterial pressure (MAP) was decreased to 40 mmHg, luid resuscitation was started in three groups of ive rats each, and in one ive-rat group no luids were given. Renal cortical microvascular perfusion (RMP) was assessed at high temporal and spatial resolution using laser speckle imaging. Additional measurements included systemic hemodynamics, renal artery blood low (RBF), blood gas analysis, creatinine clearance, and plasma ions and calculated renal oxygen delivery (DO2). Time points were: baseline, during septic shock at a MAP of 40 mmHg, and at 30 minutes of resuscitation. Results LPS infusion decreased MAP and RMP in all rats. Resuscitation with NaCl did not improve MAP (P >0.05) and appeared to increase RMP heterogeneity (0.95 ± 0.08 AU vs 1.83 ± 0.13 AU; P <0.001), metabolic acidosis (7.1 ± 0.06 vs 6.93 ± 0.05 pH; P <0.05 and 11.36 ± 1.1 vs 15.9 ± 1.4 mmol/l base excess; P <0.05), and plasma chloride ion levels (110.3 ± 0.7 vs 116.2 ± 1.7 mmol/l; P <0.05). Fluid resuscitation did not afect systemic oxygenation parameters (sO2, pO2, O2Hb) and renal DO2. Resuscitation with NaCl increased plasma levels of Na+, tubular reabsorption of Na+, and creatinine clearance compared with resuscitation with the two colloid solutions. HES-NaCl and HES-RA provided similar efects on systemic and regional hemodynamic parameters. However, while HES-RA improved RBF (2.3 ± 0.4 vs 5.7 ± 0.2), HES-NaCl did not. NaCl resuscitation worsened the metabolic acidosis, which was not afected by the two colloid solutions. The plasma HCO3– level was increased by HES-RA resuscitation (13.18 ± 2.1 vs 19.56 ± 1 mmol/l; P <0.01), whereas it was stable in the other groups. Conclusions Balanced HES preparation (HES-RA, PlasmaVolume Redibag®) in endotoxemic rats showed acute beneicial efects on kidney microcirculation and on kidney function via bicarbonate balance whereas the NaCl treatment was harmful compared with both HES groups. P502 Efects of balanced and unbalanced colloid and crystalloid solutions on renal oxygenation in a rat model of hemorrhagic shock and resuscitation E Almac, U Aksu, C Ince University of Amsterdam, the Netherlands Critical Care 2010, 14(Suppl 1):P502 (doi: 10.1186/cc8734) Introduction Hydroxyethyl starch (HES, 130 kD) dissolved either in saline (Voluven®) or in a balanced Ringer’s acetate solution (PlasmaVolume Redibag®, PVR) and Ringer’s acetate (RA) and 0.9% NaCl (NaCl) were investigated as regards their eicacy in restoring renal oxygenation in a rat model of hemorrhagic shock and resuscitation. S168 Methods In 22 anesthetized, mechanically ventilated rats, hemorrhagic shock was induced by withdrawing blood volume from the femoral artery until the mean arterial pressure (MAP mmHg) was reduced to 40 mmHg. One hour after reaching a MAP of 40 mmHg, animals were resuscitated with either Voluven® (n = 5), PVR (n = 6), RA (n = 5), or NaCl (n = 6) until a target MAP of 80 mmHg was reached. Oxygen tension in the renal cortex (CμPO2 mmHg), outer medulla (MμPO2 mmHg), and renal vein were measured using oxygen-dependent quenched phosphorescent lifetimes of Oxyphor G2. Renal artery blood low (RBF ml/minute) was measured. Renal oxygen delivery and renal oxygen consumption (DO2 and VO2 ml·minute/g) were calculated. Results During hemorrhagic shock, CμPO2, MμPO2, RBF, DO2, and VO2 decreased and O2ER increased. During resuscitation, CμPO2 and MμPO2 were increased in all groups (P <0.001) although least prominent in the NaCl group. RBF was signiicantly increased during resuscitation in all groups (PVR; 5.1 ± 0.2 P <0.001, RA; 3.5 ± 0.4 P <0.001, Voluven®; 3.4 ± 0.4 P <0.01), except for the NaCl group, and DO2 was signiicantly increased in the PVR group (0.20 ± 0.02 vs 0.39 ± 0.06; P <0.01) and RA group (0.22 ± 0.03 vs 0.41 ± 0.06; P <0.01), while this remained low in the other two groups. Fluid resuscitation was not able to restore VO2. After 1 hour of resuscitation CμPO2 was signiicantly higher in the PVR group (49.9 ± 2.4 P <0.01) and the Voluven® group (45.3 ± 5.1 P <0.05) but not in the RA group (40.6 ± 2.2 P >0.05) compared with the NaCl group (32.1 ± 2.55). Furthermore, RBF was signiicantly higher in the PVR group (5.1 ± 0.2 P <0.01) compared with the NaCl group (2.4 ± 0.5) after 1 hour of resuscitation. Conclusions Our results suggest that both colloid solutions (Voluven® and PlasmaVolume Redibag®) are preferred resuscitation luids with respect to crystalloid solutions. Moreover, the balanced colloid solution (PVR) appears to restore renal blood low and oxygenation more than the crystalloids or unbalanced colloids do in this rat model of hemorrhagic shock and resuscitation. Acknowledgements This study was supported in part by a grant from Baxter Health Care. P503 Efect of rapidly infused crystalloids on acid–base status of dehydrated patients in the emergency department H Hasman, B Comert, O Cinar, A Uzun, L Yamenel Gulhane Military Medical Academy, Ankara, Turkey Critical Care 2010, 14(Suppl 1):P503 (doi: 10.1186/cc8735) Introduction Dehydration is an important problem among patients admitted to the emergency department (ED). However, there has not yet been a consensus on the ideal luid for these patients. This study was planned to evaluate the ideal crystalloid for the patients admitted to the ED who have symptoms of dehydration. Methods We conducted a randomized controlled trial that included 90 dehydrated patients. Three groups of patients each included 30 randomized for one of the solutions Lactated Ringer’s, 0.9% NaCl or Isolyte® (Eczacıbaşı-Baxter, Turkey). Solutions were infused at a rate of 20 ml/kg/ hour for 2 hours. Venous blood sample pH, Na+, K+, Cl–, and HCO3– levels were evaluated at 0, 1, and 2 hours. Results We detected a decrease in serum pH (7.406 to 7.365) and HCO3– (23.1 to 21.5) levels at the second hour in the 0.9% NaCl group. However, in the Isolyte® group an increase in both serum pH (7.410 to 7.434) and HCO3– (23.4 to 24.4) levels were observed. In the Lactated Ringer’s group, Table 1 (abstract P503) pH HCO3 Lactated Ringer’s 0 hours 2 hours 7.396 7.408 22.8 22.4 0.9% normal saline 0 hours 2 hours 7.406 7.365 23.1 21.5 Isolyte® 0 hours 2 hours 7.410 7.434 23.4 24.4 Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S169 there was no signiicant change in serum pH and HCO3– levels. All changes were in the physiological range (Table 1). Conclusions All three crystalloid solutions can be safely used for dehydrated patients and the best metabolic proile can be maintained in patients who receive Isolyte®. P504 Impact of saline-based tetrastarch vs balanced tetrastarch and crystalloid solutions on hyperchloraemic acidosis in endotoxaemic sheep TG Kampmeier1, C Ertmer1, S Rehberg1, A Morelli2, M Lange1, C Höhn1, H Van Aken1, M Westphal1 1 University Hospital of Muenster, Germany; 2University of Rome ‘La Sapienza’, Rome, Italy Critical Care 2010, 14(Suppl 1):P504 (doi: 10.1186/cc8736) Introduction Septic shock is frequently associated with metabolic acidosis derived from increased lactic acid production and infusion of sodium chloride-based resuscitation luids. Although the impact of hyperchloraemic acidosis on outcome is still not fully understood, avoiding such a condition is desirable. The hypothesis of the present study was that resuscitation with saline-based tetrastarch solutions results in higher plasma chloride and lower base excess levels as compared with either balanced tetrastarch or crystalloid solutions in ovine endotoxaemic shock. Methods Thirty-one awake healthy ewes received a continuous infusion of Salmonella typhosa endotoxin started at 5 ng/kg/minute, which was doubled every hour until the mean arterial pressure (MAP) fell below 65 mmHg. Thereafter, sheep were randomized to receive either balanced 6% HES 130/0.4; saline-based 6% HES 130/0.4 (both HES solutions were infused up to 50 ml/kg); balanced crystalloids; or no luids. Fluid resuscitation was guided to optimize central venous pressure (8 to 12 mmHg), pulmonary arterial occlusion pressure (12 to 15 mmHg) and mixed-venous oxygen saturation (≥65%). Norepinephrine was infused to establish a MAP of 70 ± 5 mmHg, if necessary. Haemodynamic variables and blood gas analyses were determined hourly throughout the study period. Animals surviving the 12-hour intervention period were deeply anaesthetized and killed. Results Haemodynamic variables were comparable between groups. Plasma chloride concentrations were signiicantly higher, and oximetrycorrected base excess was lower in the saline-based tetrastarch group as compared with the balanced tetrastarch or balanced crystalloid group over the whole interventional period (each P <0.05). Whereas arterial pCO2 was lowest in the saline-based tetrastarch group (each P <0.05), there were no diferences between treatment groups in arterial pH. Conclusions As compared with balanced tetrastarch or crystalloid solutions, saline-based tetrastarch infusion is associated with hyperchloraemic acidosis, which is compensated by hyperventilation in awake, endotoxaemic sheep. P505 Are diferent hydroxyethyl starch solutions an independent risk factor for acute kidney injury in surgical critically ill patients? A retrospective analysis of 3,591 patients C Ertmer1, S Rehberg1, A Morelli2, TG Kampmeier1, J Wellmann1, T Volkert1, M Lange1, AK Hüsing1, H Van Aken1, M Westphal1 1 University of Muenster, Germany; 2University of Rome ‘La Sapienza’, Rome, Italy Critical Care 2010, 14(Suppl 1):P505 (doi: 10.1186/cc8737) Introduction Acute kidney injury (AKI) is a common complication associated with increased mortality among ICU patients. The purpose of the present study was to retrospectively analyze the inluence of diferent, saline-based hydroxyethyl starch (HES) solutions (tetrastarch, 6% HES 130/0.4; pentastarch, 10% HES 200/0.5) on the risk of AKI in a cohort of surgical ICU patients. Methods Data for 3,591 patients admitted to one of four ICUs of the University Hospital of Muenster from January 2000 until August 2008 were extracted from an electronic database and analyzed using univariate and multivariate logistic regression analyses. AKI was deined as grade I or higher according to the RIFLE classiication. Results Average amounts of colloid infusion per ICU day were 402 (231; 656) and 73 (36; 172) ml/day in patients treated with tetrastarch and Figure 1 (abstract P505). Risk factors for acute renal failure. pentastarch, respectively, whereas cumulative colloid amounts were 2,000 (500; 3,500) ml and 1,000 (500; 2,000) ml. Maximum daily infusion rates of 6% HES 130/0.4 and 10% HES 200/0.5 were below the pharmaceutically recommended daily dose limitations (that is, 50 and 20 ml/kg/day, respectively). The overall incidence of AKI was 20.4%. Multivariate logistic regression analysis revealed SOFA score (OR 1.597; 95% CI 1.543, 1.653), male gender (OR 1.455; 95% CI 1.153, 1.836), creatinine concentration on admission (OR 1.288; 95% CI 1.125, 1.475), and patient age (OR 1.017; 95% CI 1.009, 1.024) as independent risk factors for AKI. See Figure 1. Conclusions Neither of the investigated HES solutions (given within the recommended dose range) was an independent risk factor for AKI in the present cohort of surgical ICU patients. P506 Role of early continuous venovenous hemodiailtration in septic shock and multiorgan failure M Soliman, A Battah, H Elsherif, A Elsherif, H Khaled Nagi Cairo University, Cairo, Egypt Critical Care 2010, 14(Suppl 1):P506 (doi: 10.1186/cc8738) Introduction To evaluate early continuous venovenous hemodiailtration (CVVHDF) in patients with refractory septic shock and multiorgan failure upon mortality and morbidity in the ICU. Methods Forty patients were prospectively studied and randomly treated with either conventional treatment (20 patients; group II) or with early CVVHDF (less than 6 hours of maximal hemodynamic support) in addition to the conventional treatment (20 patients; group I). Metabolic acidosis, serum lactate and serum procalcitonin level (PCT) before and 5 days after CVVHDF were monitored to evaluate the outcome. APACHE II and ΔSOFA scoring systems were used before and 5 days after CVVHDF. Results Compared with group II, patients of group I had lower mortality (55% vs 70%) with an insigniicant P value (P = 0.54). Group I patients showed a nonsigniicant ΔSOFA (5.95 ± 4.39 vs 6.2 ± 3.3 in groups I and II, respectively, P = 0.66); regarding APACHE II scores, group I also showed statistically nonsigniicant lower igures than group II (on admission APACHE II scores were 39.35 ± 10.65 vs 41.85 ± 10 in groups I and II, respectively, P = 0.45, while on day 5 APACHE II scores were 34.8 ± 10.6 vs 36.1 ± 10.9 in groups I and II, respectively, P = 0.41). Group I patients showed lower PCT on admission and day 5 than group II patients (on admission PCT level was 0.64 ± 0.18 vs 0.68 ± 0.17 in groups I and II, respectively, P = 0.5) while the day 5 PCT level was (0.51 ± 0.15 vs 0.52 ± 0.17 in groups I and II, respectively, P = 0.83). Indicators of improvement showed a statistically signiicant diference between survivors and nonsurvivors in group I regarding serum lactate level at day 5 (P <0.001), while other indicators as fever, renal proile, WBC count, metabolic acidosis, serum lactate level on admission and platelet count were statistically insigniicant (on admission P = 0.2, 0.55, 0.45, 0.41, 0.65, 0.55, respectively, and on day 5 P = 0.37, 0.94, 0.71, 0.5, <0.001, 0.88, respectively). There was a signiicant statistical diference between survivors and nonsurvivors in group I considering the number of organ failures as less than or equal to three organs involved in comparison with more than three organs involved (P = 0.008). Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S170 Conclusions Early CVVHDF may improve the prognosis of sepsis-related multiple organ failure. Continuous rising of the serum lactate level despite CVVHDF is associated with an increased mortality rate. Of all scoring systems used, SOFA maximum, ΔSOFA and day 5 APACHE II were the most accurate prognostic indicators for mortality. Reference 1. Winchester et al.: Blood Purif 2003, 21:79-84. P507 Efect of intravenous H2S on porcine aortic occlusion-induced systemic inlammation and kidney ischemia/reperfusion injury F Wagner1, F Simon1, A Scheuerle1, M Groeger1, E Calzia1, A Soell1, O McCook1, B Stahl1, G Speit1, M Georgief1, P Radermacher1, C Szabo2, H Schelzig1 1 Ulm University, Ulm, Germany; 2University of Texas Medical Branch, Galveston, TX, USA Critical Care 2010, 14(Suppl 1):P507 (doi: 10.1186/cc8739) Introduction Both inhaled hydrogen sulide (H2S) [1] and intravenous H2S donors protected against kidney ischemia/reperfusion (I/R) injury [2-4], but all these data originate from unresuscitated rodent models. Therefore, we investigated the efect of the H2S donor Na2S in a clinically relevant porcine model of aortic occlusion-induced renal I/R injury. Methods Anesthetised and ventilated pigs received Na2S (n = 9) or vehicle (n = 10) for 2 hours before and 8 hours after 90 minutes of intra-aortic balloon occlusion-induced kidney ischemia. During reperfusion noradrenaline was titrated to keep blood pressure at baseline levels. Before Na2S, prior to aortic occlusion and at 1, 2, 4 and 8 hours of reperfusion, we measured renal blood low and function (creatinine clearance and blood levels, fractional Na+ excretion), blood cytokines (TNFα, IL-6, IL-1β) and nitrates, renal tissue DNA damage (comet assay), HO-1 and caspase-3 expression (western blotting), and NF-κB activation (EMSA). Histological damage (glomerular tubularisation [5]) was assessed immediately post mortem. Results Na2S pretreatment was associated with a progressive fall in core temperature and signiicantly lower noradrenaline infusion rates needed to achieve the hemodynamic targets. While renal blood low and fractional Na+ excretion were comparable, Na2S attenuated the fall in creatinine clearance and the rise in creatinine blood levels, respectively, which coincided with signiicantly lower IL-6, IL-1β, and nitrate blood levels. Kidney glomerular and tissue DNA damage were markedly attenuated, whereas NF-κB activation was signiicantly higher in the Na2S-treated animals. Conclusions In a clinically relevant porcine model mimicking aortic cross-clamping-induced kidney I/R injury, Na2S attenuated tissue injury and organ dysfunction as a result of reduced systemic inlammation and oxidative stress. The higher NF-κB activation and the unchanged fractional Na+ excretion were most probably due to the drop in temperature [6] and the direct efect of H2S on tubular Na+ absorption [7], respectively. Acknowledgements Supported by the DFG (SCHE 899/2-3) and Ikaria Inc. (Seattle, WA, USA). References 1. 2. 3. 4. 5. 6. 7. J Am Soc Nephrol 2009, 20:1901-1905. Lab Invest 2008, 88:1038-1048. Eur J Pharmacol 2009, 606:205-209. Am J Physiol Renal Physiol 2009, 297:F27-F25. Nephron Exp Nephrol 2007, 105:e33-e40. Am J Physiol Gastrointest Liver Physiol 2007, 292:G201-G207. J Pharmacol Exp Ther 2009, 329:1056-1062. P508 Survival improvement in pigs with liver failure and superimposed sepsis by a new liver support system (Hepa Wash®) A Al-Chalabi1, E Matevossian1, AK Preissel1, H Yan1, A Geiger1, E Nairz1, P Schimmel1, C Schreiber1, Z Yang1, B Kreymann2 1 Klinikum Rechts der Isar, München, Germany; 2Hepa Wash GmbH, Munich, Germany Critical Care 2010, 14(Suppl 1):P508 (doi: 10.1186/cc8740) Introduction Liver failure is often complicated by sepsis. Available liver support systems (LSS) failed to show survival beneits. Hepa Wash® (HW) is a newly developed LSS based on use of recycled albumin dialysate. The Figure 1 (abstract P508). Hepa Wash® stabilizes mean arterial pressure in liver failure and sepsis. study aim is to evaluate its safety and eicacy in an animal model that combines liver failure with sepsis. Methods Female German Landrace pigs (~60 kg) were randomly allocated to HW (n = 5) and control (n = 5) groups. On day 0 ischemic and cholestatic liver injury was induced by functional end-to-side portacaval shunt and bile duct ligation. Animals were returned then to the stall for observation. On day 3 the second phase of the experiment was started. Endotoxin was administered intravenously at an initial dose of 4 μg/kg/hour with a stepwise twofold increment every hour and stopped after 7.5 hours. HW was started 2.5 hours after endotoxemia and continued for 7 hours. Results On day 3, animals (n = 10) had hyperbilirubinemia (5.2 ± 0.3 mg/dl; mean ± SEM) and hyperammonemia (264 ± 38 μg/dl). Endotoxemia in control animals resulted in severe multisystem organ failure and death (after 6.4 ± 0.3 hours) although they received only one-third of the total endotoxin dose on average. HW improved cardiovascular (Figure 1), cerebral, respiratory and renal parameters and eliminated surrogate parameters as bilirubin (2.8 ± 0.5 vs 5.2 ± 0.3 mg/dl P <0.05) and ammonia (189 ± 38 vs 1,108 ± 455 μg/dl, P <0.05). All animals in the HW group survived the 10-hour observation period (P <0.05). We did not notice any adverse efects during treatment. Conclusions Hepa Wash® was safe and efective at improving survival in a swine model of liver failure and sepsis due to amelioration of the major organ functions and removal of protein-bound and water-soluble toxins. P509 Increased glomerular iltration in the critically ill patient receiving anti-infective treatment B Claus, K Colpaert, E Hoste, J Decruyenaere, J De Waele Ghent University Hospital, Ghent, Belgium Critical Care 2010, 14(Suppl 1):P509 (doi: 10.1186/cc8741) Introduction Little is known about the occurrence of increased glomerular iltration rates (GFR) in critically ill patients. Increased GFR may in theory lead to subtherapeutic concentrations of life-saving drugs. The aim of this study was to evaluate the occurrence rate and pattern of increased GFR in critically ill patients receiving anti-infective treatment (AIT). Methods Prospective evaluation of consecutive ICU patients during a 6-week period, treated with anti-infective drugs, either therapeutically or prophylactically; dialysed patients were excluded. Patient characteristics: retrieved from the computerized Intensive Care Information System. Surrogate measure for GFR: the 24-hour urinary creatinine clearance (Ccr) calculated per day of AIT. Increased GFR: Ccr >120 ml/minute. Statistical analysis with SPSS 17.0: Student’s t test, chi-square or Fisher’s exact test. Data expression: median and interquartile range (IQR). Multivariate analysis: logistic regression analysis with increased GFR as dependent variable. Results One hundred and forty-one (94 male) patients were included; median age was 59.9 (50.3 to 70.1); 80 (56.7%) were surgical ICU (SICU) patients. Most common infection types were pneumonia (59.2%) and intra-abdominal infection (9.9%). Prophylactic use was 17.6% of all AIT. Median length of stay 4.6 days; ICU mortality 5.7%. Median Ccr in the Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S171 whole patient group was 97.0 ml/minute (57.5 to 164.5). In total, 753 AIT days were available for analysis in which 302 days of increased GFR were present (40.1%). Seventy-six patients (53.9%) had an episode of increased GFR at some time during AIT. In 31 patients (22.0%) GFR was increased throughout the whole episode of AIT. Patients with increased GFR were signiicantly younger (54.2 vs 65.6, P <0.001) and there was a trend towards a higher incidence of increased GFR in patients treated for infections, in male and in SICU patients. Multivariate analysis showed that age (OR 0.93 per year), therapeutic administration of AIT (OR 5.49), and SICU admission (OR 2.27) were independently associated with increased GFR. Conclusions Increased GFR were a frequent inding in critically ill patients receiving AIT, and was associated with younger age and SICU admission. P510 Therapeutic plasma exchange in children with acute liver failure: assessment of laboratory parameters D Demirkol, O Yanar, N Gerenli, A Citak, I Ozden, S Cantez, O Durmaz, M Karabocuoglu Istanbul University, Istanbul, Turkey Critical Care 2010, 14(Suppl 1):P510 (doi: 10.1186/cc8742) Introduction The aim of this study is to analyze the efect of therapeutic plasma exchange (TPE) on biochemical and coagulation parameters. Methods We enrolled all children who were admitted to the pediatric ICU with diagnosis of acute liver failure and underwent TPE between December 2005 and December 2009. Serum prothrombin time, International Normalized Ratio, total and direct bilirubin, aminotransferases and serum ammonia values were recorded before and after TPE sessions. Results Fourteen patients (male/female, 4/10, median age 8.5 years) underwent a total of 37 TPE sessions. Acute liver failure was induced by viral hepatitis in ive cases, Wilson disease in four cases, toxins in four cases and autoimmune hepatitis in one case. When compared with baseline, there were signiicant improvements in laboratory parameters (Table 1). Five of the 14 patients (35.7%) died in the pediatric ICU, ive patients underwent liver transplantation. Four patients (28.5%) survived with extracorporeal liver support. No serious adverse efect of TPE was observed in the patients during or after completion of TPE. Conclusions TPE is efective in improving liver biochemistry tests in children with liver failure. Expected changes in laboratory parameters after TPE must be considered especially in deciding for liver transplantation. Reference 1. Singer AL, Olthof KM, Haewen K, Rand E, Zamir G, Shaked A: Role of plasmapheresis in the management of acute hepatic failure in children. Ann Surg 2001, 234:418-424. P511 New markers of inlammation-induced renal injury subside when endotoxin tolerance develops in humans as measured by urine proteomics S Heemskerk, A Draisma, C Laarakkers, J Van der Hoeven, R Masereeuw, P Pickkers Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands Critical Care 2010, 14(Suppl 1):P511 (doi: 10.1186/cc8743) Introduction Sepsis has been identiied as the most common cause of renal injury in ICUs although the pathophysiology is not well understood. No large clinical studies are available that show an improvement of renal function in patients with sepsis and this may be related to the lack of early diagnostic tests that indicate the onset of renal injury. The aim of the current study was to search for potential new early markers of renal injury during acute endotoxemia and to investigate whether renal injury can be ameliorated by the induction of lipopolysaccharide (LPS) tolerance. Methods Five healthy males received intravenous bolus injections of 2 ng/kg/day Escherichia coli LPS for 5 consecutive days. We used surfaceenhanced laser desorption/ionization time-of-light mass spectrometry (Seldi-TOF MS). This approach allows for rapid high-throughput proiling of multiple urine samples and detects low molecular weight biomarkers. Results Repeated LPS administrations induced a diminished glomerular iltration rate of 33 ± 7% (P = 0.02) on day 2 and an increase in serum creatinine of 11 ± 3% (P = 0.002) on day 3, which was associated with the appearance of 15 peak intensities in the urinary protein proile including an increase in β-microglobulin levels (P = 0.04) 6 hours after the irst LPS administration. Four of the 15 peak intensities on day 1 correlated with serum creatinine levels on day 3; 3,950, 4,445, 6,723 and 7,735 m/z (P = 0.03; 0.01; 0.02 and 0.05, respectively). With the development of LPS tolerance, renal function was restored, relected by a decrease in serum creatinine and β-microglobulin levels to baseline (P = 0.2 and 0.4, respectively, between days 1 and 5), and by attenuated peak intensities in the urinary protein proile (P <0.0001 for all 15 peak intensities). Conclusions In conclusion, renal injury occurs during repeated endotoxemia and can be predicted by new urinary markers using proteome research. The four markers that correlated with the extent of renal injury may represent potential new biomarkers for renal injury and need further identiication. The inlammation-induced renal injury subsided when LPS tolerance developed after 5 consecutive days of LPS administrations. P512 Extraction and puriication of 1-hydroxymidazolam glucuronide from ultrailtrate C Mckenzie1, D Naughton2, G Davies3, D Treacher1 1 Guy’s and St Thomas’ NHS Foundation Trust, London, UK; 2Kingston University, London, UK; 3King’s College, London, UK Critical Care 2010, 14(Suppl 1):P512 (doi: 10.1186/cc8744) Introduction We developed a technique for detection of MDZ and 1-hydroxymidazolam glucuronide (1-OHMG). No commercial source of 1-OHMG prevented assay development. 1-OHMG had pharmacological activity and is renally excreted. We postulated that ultrailtrate (UFR) would be rich in 1-OHMG. We describe a method to purify 1-OHMG from UFR. Methods Ethics approval was granted. To purify, UFR was extracted on a C-18 column, it was washed and eluted. HPLC-MS separation was performed. The 1-OHMG (mol. wt 517/ 518 in MS) was desiccated and re-dissolved four times to maximise purity. Electrospray (ESI) mass spectrometry (MS) characterised 1-OHMG. The purity was calculated using NMR. A calibration plot of 1-OHMG, MDZ and DZP (internal standard) for HPLC-MS was performed. Results 1-OHMG identity was conirmed using MS/MS (Figure 1). Two milligrams of 1-OHMG was puriied from 5,000 ml UFR. The 1-OHMG was 98% pure (NMR). The extinction coeicient was identical to MDZ. The calibration plot resulted in correlation of 0.912. The assay was applied into clinical practice, to report sera and UFR levels. Table 1 (abstract P510). Biochemical and coagulation parameters before and after TPE Variable Before TPE After TPE Delta variable PT (sec) 40.9 (32.5 to 47.5) 21.1 (18.1 to 25.0) 17.8 (10.2 to 26.1) 0.0003 3.6 (3.1 to 4.6) 1.7 (1.5 to 2.3) 1.7 (1.3 to 27.8) 0.0002 TB (mg/dl) 17.7 (11.7 to 21.5) 14.2 (9.6 to 18.0) 3.2 (1.1 to 6.0) 0.0006 DB (mg/dl) 10.3 (7.3 to 17.2) 7.9 (4.8 to 14.2) 1.9 (0.8 to 4.8) 0.0001 ALT (U/l) 122.5 (61.1 to 370) 87.5 (54 to 197.5) 38.1 (7 to 109.5) 0.0001 AST (U/l) 247.5 (122 to 399) 178 (85.5 to 272) 66.5 (14.1 to 223) 0.0002 Ammonia (mmol/l) 143.2 (81.5 to 195) 97.0 (71 to 150.5) 11.5 (3.5 to 59) 0.0003 INR P value Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S172 Figure 1 (abstract P512). Centroided MS of puriied 1-OHMG. Conclusions We were able to extract and purify an active drug metabolite from UFR. Five litres of UFR resulted in 2 mg 1-OHMG. This is a potentially rich source of drugs or drug metabolites, allowing pharmacokinetic studies greatly required in critical illness. Reference 1. McKenzie et al.: Diferentiating MDZ oversedation from neurological damage in the intensive care unit. Crit Care 2005, 9:32-33. P513 Continuous renal replacement therapy: are we getting the dose right? S Martin, M Al-Haddad Western Inirmary, Glasgow, UK Critical Care 2010, 14(Suppl 1):P513 (doi: 10.1186/cc8745) Introduction The Intensive Care Society recommends achieving a dose of 35 ml/kg/hour in 85% of patients receiving continuous renal replacement therapy (CRRT). However, a recent multicentre trial concluded there was no beneit of using 40 ml/kg/hour versus 25 ml/kg/hour. The extra cost of high-dose RRT has not been quantiied. At our institution the target dose is 35 ml/kg/hour. Methods Patients receiving renal replacement therapy from April to September 2009 were identiied using Careview, an electronic patientcare record system. The eluent rate (ml/hour) was used to calculate the dose and adjusted for weight. A telephone survey of ICUs examined the dose and mode of CRRT used in Scotland. Results Thirty-ive patients, mean age 62, received CRRT with a mean duration of RRT of 78 hours. Twenty-three patients (66%) were admitted Figure 1 (abstract P513). Mean dose of RRT for each patient at Western Inirmary. with sepsis. Continuous venovenous haemodiailtration was the initial mode in 31 patients (89%). Ten patients were excluded from the dose analysis because no weight was documented. The mean dose actually delivered per patient was 50 ml/kg/hour. If 25 ml/kg/hour had been given then 40% less RRT luid could have been used. The Scottish telephone survey revealed that one-third of Scottish ICUs routinely use 35 ml/kg/ hour or more. If 25 ml/kg/hour was used routinely in these units alone, then over €24,000 could be saved per annum. Conclusions The dose of CRRT given for each patient at our institution currently exceeds the target dose by 43%. Using 25 ml/kg/hour as the standard dose would provide a signiicant cost saving to the NHS in Scotland and to ICUs throughout Europe. Reference 1. Bellomo R, Cass A, Cole L, et al.: Intensity of continuous renal-replacement therapy in critically ill patients. N Engl J Med 2009, 361:1627-1638. P514 Use of CRRT-CVVH in a hemato-oncological ICU in patients treated with deibrotide for veno-occlusive disease in patients after allogeneic hematopoetic stem cell transplantation: single-center experience M Navratil, Z Koristek, F Folber Masaryk University Hospital, Brno, Czech Republic Critical Care 2010, 14(Suppl 1):P514 (doi: 10.1186/cc8746) Introduction Complex care in the hemato-oncological ICU sometimes requires the use of CRRT. As the hemato-oncological patients have some speciications we retrospectively followed up the results of our efort in patients with acute renal failure due to veno-occlusive disease (VOD) after allogeneic hematopoietic stem cell transplantation. VOD is one of the most severe early complications in this type of patients and its mortality is high. Methods From 1 January 2007 to 30 October 2009 we performed 94 procedures (one procedure = 24 hours) in 15 patients with VOD and acute renal oligo-anuric failure. As a standard in our ICU we perform CVVH with post dilution on a Fresenius Multiiltrate machine. The key drug for the treatment of VOD is deibrotide and the patients were severely thrombocytopenic, we have not used any anticoagulation in the CVVH set. The dose of deibrotide ranged from 10 to 20 mg/kg/day according to the severity of thrombocytopenia and eventually hemorrhagic symptoms. Blood count, acid–base balance and biochemistry were monitored at least twice daily. The thrombocytopenia was corrected with the donor platelets and the platelet level was sustained at 20 x 109l. Results The introduction of CVVH in all 15 patients dramatically helped to overcome the severe part of VOD until the deibrotide helped to restore Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 the right function of vascular endothelium. None of the 15 patients died from VOD as a cause of death. Surprisingly, the median patency of the CVVH tubing set was 46 hours despite no anticoagulation in the tubing set. Deibrotide is eicient in preventing coagulation in the tubing set. No serious hemorrhagic events were observed. The luent maintenance of luid balance, the removal of waste products of metabolism and the maintenance of acid–base balance were very important for the patient in the critical point of advanced VOD. Conclusions CVVH is an integral part of intensive care in hemato-oncology and the use of this therapeutic modality in patients with VOD with acute renal failure can signiicantly improve the results of our therapeutic eforts. P515 Comparison of the eicacy and safety of two regional citrate anticoagulation protocols using acid citrate dextrose A or Prismocitrate 10/2, in patients with acute renal failure undergoing continuous venovenous haemodiailtration EL Ooi, TW Lim, N Lim Changi General Hospital, Singapore Critical Care 2010, 14(Suppl 1):P515 (doi: 10.1186/cc8747) Introduction Continuous renal replacement therapy (CRRT) is the treatment of choice for acute renal failure in critically ill patients. Our study compared the eicacy and safety of regional citrate anticoagulation (RCA) with acid citrate dextrose A (ACD-A) against Prismocitrate 10/2 (Gambro). Use of Prismocitrate 10/2 eliminates the need for a separate infusion pump for ACD-A as it doubles as replacement luid and anticoagulant. This removes a source of error in the calculation of luid balance. The combination of tri-sodium citrate and citric acid in Prismocitrate 10/2 avoids the metabolic alkalosis associated with ACD-A [1,2]. Methods This was a prospective sequential cohort study. All patients admitted to the surgical ICU who required CRRT for ARF were recruited. Group A, using ACD-A, was recruited from October 2007 to September 2008 (n = 23). Group B, using Prismocitrate 10/2, was recruited from October 2008 to September 2009 (n = 20). We evaluated the incidence of metabolic alkalosis and other biochemical changes, azotemia control, ilter lifespan and complications. Results The incidence of metabolic alkalosis in Group B from treatment day 2 onwards was signiicantly lower than Group A. The Group A median pH was 7.42 (6.81 to 7.62) compared with Group B pH 7.35 (7.2 to 7.49), P = 0.001. The control of electrolytes and azotemia was not signiicantly diferent. The mean ilter duration was 58.8 hours (95% CI 38.0 to 79.6) for Group A and 61.8 hours (95% CI 45.8 to 77.8) for Group B (P = 0.678). Longitudinal analysis revealed a statistically signiicant result for reduced metabolic alkalosis for Group B. (standard bicarbonate P <0.001, base excess P <0.001). Repeat treatment sessions also showed a statistically signiicant reduction of metabolic alkalosis using Prismocitrate 10/2 rather than ACD-A (P = 0.029). Conclusions RCA with Prismocitrate 10/2 reduces the incidence of metabolic alkalosis associated with ACD-A. This regime is safe, feasible and improved patient safety, with no increase in complication rates. Our unit has now converted to Prismocitrate 10/2 for RCA. References 1. 2. Silverstein FJ, et al.: Metabolic alkalosis induced by regional citrate hemodialysis. ASAIO Trans 1989, 35:22-25. Morgera S, et al.: Metabolic complications during regional citrate anticoagulation in continuous venovenous hemodialysis: a single center experience. Nephron Clin Pract 2004, 97:c31-c136. P516 Addition of prostacyclin to heparin does not prolong circuit life during continuous haemoiltration M Ostermann, L Tovey, H Dickie, R Beale Guy’s and St Thomas’ Foundation Hospital, London, UK Critical Care 2010, 14(Suppl 1):P516 (doi: 10.1186/cc8748) Introduction Premature circuit clotting is a major problem during continuous venovenous haemoiltration (CVVH). Some studies have suggested that circuit life can be improved by adding epoprostenol to heparin. S173 Methods Retrospective review of mean circuit patency in patients on noncitrate-based anticoagulation regimens during CVVH in a 30-bed multidisciplinary ICU between October 2008 and May 2009. Circuits which were discontinued electively were excluded from the analysis. Results Patency data were available for 486 noncitrate circuits. There was no signiicant diference in mean circuit life between heparin given via circuit (n = 169 circuits; mean circuit life 19.8 hours) and epoprostenol alone (n = 119 circuits; mean circuit life 20.9 hours). In a small group of patients on heparin via the circuit, epoprostenol was added for patency reasons (n = 19 circuits). In this group, the mean circuit life was only 15 hours. Circuits of patients on systemic heparin (n = 100) lasted for a mean of 23.5 hours. In a small group of patients, epoprostenol was added via the circuit (n = 32 circuits). The mean circuit life was 28.9 hours (P >0.05). Other types of noncitrate anticoagulation were activated protein C and lepuridin, alone or in combination with heparin (n = 47 circuits). Conclusions In our practice, anticoagulation with epoprostenol alone led to similar circuit survival as heparin administered via the circuit. Adding epoprostenol to heparin did not signiicantly prolong the mean circuit life. Further analysis of circuit patency in individual patients is needed to determine the characteristics of patients who may beneit and for whom the extra cost could be justiied. P517 Recurrent early ilter clotting in regional citrate anticoagulated continuous venovenous hemodialysis due to undetected antibodies to heparin–platelet factor 4 complexes T Slowinski, I Lieker, M Sander, D Khadzhynov, S Morgera, H Neumayer, H Peters Charité Campus Mitte, Berlin, Germany Critical Care 2010, 14(Suppl 1):P517 (doi: 10.1186/cc8749) Introduction We recently published a citrate anticoagulated continuous venovenous hemodialysis (citrate-CVVHD) protocol with variable treatment dose. The protocol was safe and easy to handle and the mean ilter lifetime was 61.5 hours [1]. We here report ive cases with unexplained recurrent early ilter clotting beside efective citrate anticoagulation due to undetected antibodies to heparin–platelet factor 4 complexes (hep-PF4 ab). Methods Regionale citrate anticoagulation was performed with variable treatment dose using the MultiFiltrate™ CRRT device (Fresenius, Germany) in CVVHD mode. Between May 2008 and August 2009 we detected ive cases on the ICU. All had acute kidney injury with need for RRT. Underlying diseases were: three sepsis, one cardiac surgery, one abdominal surgery. All patients were anticoagulated with heparin or fractionated heparin for more than 10 days before initiation of citrate-CVVHD. At the time of initiation of citrate-CVVHD, none of the patients had clinically evident signs of thomboembolism. Results The mean ilter lifetime before diagnosis of hep-PF4 ab was 8 (range 1.3 to 14) hours. Postilter ionized calcium concentrations were always in the demanded range (mean 0.28, range 0.24 to 0.35 mmol/l). The mean thrombocyte count was 160/nl (range 48 to 215) at time of initiation of citrate-CVVHD. Thrombocyte counts fell to a mean 114/nl (range 36 to 177) within 5 days. Mean time to testing for and diagnosis of hep-PF4 ab was 6 (range 3 to 12) days. After positive testing (HIPA) for hep-PF4 ab, heparin was stopped and all patients received argatroban with a mean PTT of 83 (range 48 to 119) seconds. Under systemic anticoagulation with argatroban, the ilter lifetime of citrate-CVVHD increased to a mean 58 (range 18 to 96) hours. Within 14 days after initiation of citrate-CVVHD, three patients had a diagnosis of a clinically signiicant thrombembolic event. Conclusions In patients on the ICU with moderate–low thrombocyte count and without clinically evident signs of thomboembolism, often sepsis or the state of critical illness is assumed as the cause for decreasing platelet counts and tests for hep-PF4 ab are not performed. In cases of undetected and untreated hep-PF4 ab, ilter clotting can occur beside efective citrate anticoagulation in CVVHD. In cases of unexplained recurrent early ilter clotting in citrate-CVVHD, patients should be carefully examined for underlying hep-PF4 ab and heparin-induced thrombocytopenia. Reference 1. Morgera et al.: Crit Care Med 2009, 37. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P518 Pilot study on a regional citrate anticoagulated continuous venovenous hemodiailtration protocol with variable treatment dose T Slowinski, I Lieker, D Khadzhynov, M Sander, S Morgera, H Neumayer, H Peters Charité Campus Mitte, Berlin, Germany Critical Care 2010, 14(Suppl 1):P518 (doi: 10.1186/cc8750) Introduction In order to add convective solute transport to a recently described citrate-CVVHD protocol, we established a citrate anticoagulated continuous venovenous hemodiailtration (citrate-CVVHDF) protocol with variable treatment dose. Citrate-CVVHD has been shown to be safe and easy to handle [1]. Being based on dialysis, however, citrate-CVVHD primarily relies on difusive solute transport. To also allow convective transport, we designed a new citrate-CVVHDF protocol with a postdilution hemoiltration dose. Methods Prospective observational study. A CVVHDF-based citrate anticoagulation protocol on the MultiFiltrate™ CRRT device (Fresenius Medical Care (FMC), Germany) using a 4% trisodium citrate solution, the dialysate luid Ci-Ca™ Dialysate K2 (FMC), and a continuous calcium chloride (91 mmol/l) infusion. For the iltration dose we used a standard bicarbonate-bufered substitution luid (MultiBic™; FMC) in postdilution. Ten patients on the ICU with acute kidney injury and need for RRT were included. For variable doses, patients were divided into three groups according to their body weight (1: <60 kg, 2: 60 to 90 kg, 3: >90 kg). The initial lows for dialysate/substitution luid in the groups were 1,400/800, 1,800/1,000, and 2,200/1,200 ml/hour, blood low 80, 100, and 120 ml/ minute, citrate low 145, 175, and 220 ml/hour, and calcium low 32, 45, and 57 ml/minute. Citrate low was adjusted to postilter ionized calcium (iCa) measurements, target range 0.25 to 0.35 mmol/l. Calcium low was adjusted to patients’ systemic iCa. The treatment time was limited to 72 hours. Results Eight of 10 patients reached the maximum treatment time of 72 hours without clotting. In one patient the treatment had to be stopped after 50 hours because of central venous catheter low problems and one patient died after 54 hours. Acid–base control: mean (95% CI) pH; st-bicarbonate at 48 hours: 7.42 (7.38 to 7.44); 24.6 (21.3 to 27.8) mmol/l, and at 72 hours: 7.39 (7.35 to 7.43); 25.0 (21.3 to 27.6) mmol/l. Electrolyte control: mean (95% CI) s-sodium; s-potassium at 48 hours: 139 (137 to 141); 4.8 (4.4 to 5.2) mmol/l, and at 72 hours: 139 (137 to 142); 4.9 (4.4 to 5.4) mmol/l. Mean (95% CI) treatment dose was 41 (37 to 46) ml/kg/hour, mean (95% CI) s-urea at 48 hours: 51 (37 to 66) mg/dl, and at 72 hours: 50 (35 to 65) mg/dl. Conclusions The citrate-CVVHDF protocol allows combined hemodialysis and hemoiltration in CRRT with variable treatment dose and with the advantages of regional citrate anticoagulation. In this pilot study, in 10 patients the ilter run-time in citrate-CVVHDF was remarkable and metabolic control excellent. Reference 1. Morgera et al.: Crit Care Med 2009, 37. P519 Characteristics and outcome of patients treated with renal replacement therapy: single-center, 2-year experience B Kovacevic, S Gavrilovic, D Obradovic, M Kojicic, U Batranovic Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia Critical Care 2010, 14(Suppl 1):P519 (doi: 10.1186/cc8751) Introduction Continuous renal replacement therapy (CRRT) is frequently used among hemodynamically unstable critically ill patients with acute renal failure (ARF). However, data regarding management of these patients in Serbia are scarce. CRRT has been available at our institution since 2007. The objective of this study was to describe characteristics and outcome of patients treated with renal replacement therapy in a single tertiary-care center in Serbia. Methods In this retrospective observational study we reviewed medical records of adult (≥18 years) patients treated in the ive-bed ICU at the Institute for Pulmonary Diseases in Sremska Kamenica, Serbia who underwent CRRT from April 2007 to November 2009. S174 Results From the total 314 patients treated in the ICU, 29 (9.2%), 17 men, median age 54 years (interquartile range (IQR) 48 to 68), underwent CRRT. Patients were mostly nonsurgical (n = 28, 96%). Main admission diagnoses were septic shock (n = 11) and pneumonia (n = 9). The median APACHE II score was 27 (IQR 19 to 32), and SOFA day 1 was 10 (IQR 5 to 13). Seventeen patients (58.6%) had chronic co-morbidities; Charlson score median 2 (IQR 0.75 to 3). Twenty-four patients required mechanical ventilation, and 13 were diagnosed with acute respiratory distress syndrome. Slow continuous ultrailtration was used in four patients (13.7%), hemodiailtration (CVVHDF) modality in 13 (44.8%), hemodialysis (CVVHD) in 11 (37.9%). Median time on CRRT was 3 days (IQR 2 to 4). Five patients (17%) had a complete recovery of renal function at the time of ICU discharge. Median hospital length of stay was 12 days (IQR 5 to 20) and hospital mortality was 69%. Conclusions The need for CRRT in the observed population is substantial. Future studies are warranted to determine the impact of introduction of CRRT on hospital mortality in Eastern European countries and to provide future strategies for improving patient care in these settings. P520 Renal function in living related kidney donors above the age of 70 V Milic, N Vukovic, A Pavlovic, S Pavlovic Clinical Center Nis, Serbia Critical Care 2010, 14(Suppl 1):P520 (doi: 10.1186/cc8752) Introduction Living related kidney donors are highly motivated for donation. Older donors may have increased risks in the perioperative and postoperative period. Age limits for donors was insisted on in the past. The glomerular iltration rate in older people is only slightly lower than in young individuals in the absence of primary renal disease or confounding cardiovascular disease. The aim of the study was to assess renal function of living related donors above the age of 70 in the early postoperative period. Methods From March 2007 to November 2009, in Clinical Centre Nis, 25 living related donors donated their kidneys. The serum creatinine and calculated creatinine clearance (MDRD formula) were evaluated preoperatively, irst, third and ifth postoperative days in the group under (U) and in the group above (A) the age of 70. Results There were 16 donors in group U (mean age 59, SD 5.38) and nine donors in group A (mean age 72.4, SD 1.88). The mean serum creatinine level in group U was 64.66 μmol/l (SD 12.22), 120.2 μmol/l (SD 26.04), 120.91 μmol/l (SD 21.68) and 116.07 μmol/l (SD 21.35) preoperatively, on the irst, third and ifth postoperative days, respectively. In group A the mean serum creatinine level was 84.58 μmol/l (SD 23.63), 150.64 μmol/l (SD 38.67), 149.49 (SD 43.68) and 148.36 μmol/l (SD 39.08) preoperatively, irst, third and ifth postoperative days, respectively. Calculated creatinine clearance in group U was 102.62 ml/minute/1.73 m2 (SD 20.61), 50.44 ml/minute/1.73 m2 (SD 10.28), 48.69 ml/minute/1.73 m2 (SD 7.88) and 51.62 ml/minute/1.73 m2 (SD 8.96) preoperatively, irst, third and ifth postoperative days, respectively, and in group A 78.11 ml/minute/1.73 m2 (SD 23.31), 39.11 ml/minute/1.73 m2 (SD 10.35), 40.56 ml/minute/1.73 m2 (SD 12.31) and 40.44 ml/minute/1.73 m2 (SD 11.36) preoperatively, irst, third and ifth postoperative days, respectively. There is a statistically signiicant diference in serum creatinine level between groups A and U preoperatively (P = 0.039) and on the ifth postoperative day (P = 0.043), and there is a statistically signiicant diference in glomerular iltration rate between groups A and U preoperatively (P = 0.019), on the irst (P = 0.018) and ifth postoperative days (P = 0.024). Conclusions Deterioration of residual kidney function in the early postoperative period is higher in living donors above the age of 70. Patients over the age of 70 must be accepted with care for kidney donation. P521 Augmented renal clearance in traumatic brain injury A Udy, R Boots, S Senthuran, J Stuart, R Deans, M Lassig-Smith, J Lipman Royal Brisbane and Women’s Hospital, Brisbane, Australia Critical Care 2010, 14(Suppl 1):P521 (doi: 10.1186/cc8753) Introduction Use of hypertonic saline and/or vasopressor infusion to achieve a desired cerebral perfusion pressure (CPP) in traumatic brain Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 injury (TBI) is common. We hypothesised that the use of such therapies would signiicantly augment creatinine clearances (CrCl) in this population. Methods Head-injured patients requiring hyperosmolar therapy using 3% or 20% saline solutions and/or norepinephrine infusion for the maintenance of a CPP >60 mmHg were recruited into the study. Additional management was consistent with local practice and in line with the Brain Trauma Foundation guidelines [1]. An 8-hour CrCl, physiological variables, luid balance, and medications were recorded daily during active management of CPP. A further CrCl was collected just prior to discharge (of CPP therapy), and if this was elevated, was repeated on the ward. Augmented renal clearance (ARC) was deined as a CrCl >160 ml/minute/1.73m2 for males and >150 ml/minute/1.73m2 for females [2]. Results Twenty consecutive patients were enrolled. The average ICU length of stay was 15 days (CI 95% 11 to 18), and time to study entry averaged 2.3 days (CI 95% 1.7 to 2.8). All patients received norepinephrine (n = 20), 85% (n = 17) received hypertonic saline, and therapy lasted on average 7.6 days (CI 95% 5.6 to 9.5). ARC was demonstrated in 17 (85%) patients at any point during active management of CPP. The mean maximum CrCl was 179 ml/ minute/1.73 m2 while on CPP therapy (CI 95% 159 to 198) returning to a mean CrCl of 111 ml/minute/1.73 m2 (CI 95% 91 to 131, P <0.001) when measured in the ward. The mean CrCl in the ICU while not receiving CPP therapy was 150 ml/minute/1.73 m2 (CI 95% 134 to 167, P = 0.03). The mean time to reach peak CrCl while on active treatment was 4.7 days (CI 95% 3.0 to 6.4). Norepinephrine use, saline loading, mean arterial pressure, and central venous pressure, predicted CrCl on the day of measurement. Conclusions ARC is common in head-injured patients receiving active management of CPP and persists even after ceasing such therapy. This has signiicant implications for appropriate dosing of renally excreted drugs in this setting. References 1. 2. Bratton SL, et al.: Guidelines for the management of severe traumatic brain injury. IX. Cerebral perfusion thresholds. J Neurotrauma 2007, 24(Suppl 1):S59-S64. Stevens LA, et al.: Assessing kidney function – measured and estimated glomerular iltration rate. N Engl J Med 2006, 354:2473-2483. P522 Pressure-controlled hemorrhagic shock in mice: a new model of acute kidney injury N Mayeur1, V Minville1, A Jaafar2, I Tack2 1 CHU Purpan, Toulouse, France; 2CHU Rangueil, Toulouse, France Critical Care 2010, 14(Suppl 1):P522 (doi: 10.1186/cc8754) S175 Figure 2 (abstract P522). Tubular injury score at H3, D2, D6 and D21. *P <0.05 and ** P <0.01. Methods We irst determined shock and resuscitation modalities in a C57/Bl6 mice population. A femoral arterial catheter was used for pressure control and bleeding and a central jugular catheter for anesthesia and resuscitation. We secondly explored renal repercussions of a 2-hour shock duration at 35 mmHg mean arterial pressure. We assessed successively the glomerular iltration rate (GFR), histological kidney injury score and performed real-time PCR after the procedure. The shock group was compared with sham mice and with a control group that underwent no procedure (n = 5 in each group). Results The shock group GFR was decreased 2 (D2) and 6 (D6) days after shock when compared with control and sham (Figure 1). This AKI was intrinsic as showed by the Na/K urinary ratio increase and the decrease in urine concentration ability. Tissular damage prevailed in the outer medulla with a maximal expression at D6 (paucicellular tubular epithelium, intratubular casts) (Figure 2). These lesions are associated with an increase of tissular KIM-1 and HIFs mRNA. Despite GFR normalization, the shock group showed discreet defect in urine concentration ability and a slight peritubular ibrosis 3 weeks after shock. Conclusions This new model of AKI based on hypotension opens new perspectives in the ield of short-term and long-term kidney function following AKI. Reference 1. Introduction At the present time, mice models have failed to reproduce human acute kidney injury (AKI) and new relevant models of AKI are required [1]. In this study we developed a model of AKI in mice based on pressure-controlled hemorrhagic shock that closely reproduces hypotension involved in most of human ischemic AKI. Figure 1 (abstract P522). Glomerular iltration rate 2 (D2), 6 (D6) and 21 (D21) days after the procedure. Rosen S, et al.: J Am Soc Nephrol 2008, 19. P523 Continuous urinary electrolyte measurement in a swine model of mechanical ventilation D Febres1, T Langer1, M Cressoni1, A Protti1, S Coppola1, C Mietto1, A Santini1, L Lombardi2, M Lazzerini2, P Cadringher1, P Bertoli3, L Gattinoni1 1 Università degli studi di Milano, Milan, Italy; 2Fondazione IRCCS Ospedale Maggiore Policlinico Mangiagalli e Regina Elena, Milan, Italy; 3Università degli studi di Milano, Centro di Ricerche Chirurgiche Precliniche, Milan, Italy Critical Care 2010, 14(Suppl 1):P523 (doi: 10.1186/cc8755) Introduction The kidney is the organ of the human body designed to sense and regulate intravascular volume. The KING (Kidney Instant Monitoring; Orvim, Paderno Dugnano, Italy) is a new device that allows continuous measurement of urinary electrolytes and real-time body response to changes in intrathoracic and intra-abdominal pressures and to lung injury. Methods Sixteen pigs (weight 20 ± 3 kg) were anaesthetized, tracheotomized, catheterized and mechanically ventilated. Pigs were ventilated for approximately 10 hours with a TV of 10 ml/kg, RR 15 breaths/minute, FIO2 0.5 and no PEEP. After TV was increased, pigs were divided into two groups: eight pigs with a lower TV and eight pigs with higher TV. A variable dead space was added to maintain normocapnia. Pigs were mechanically ventilated with the new TV up to 48 hours. The KING measured urinary output and urinary concentration of sodium and potassium every 10 minutes. NaCl 0.9% was exclusively infused. The average urinary concentration of each electrolyte was expressed as the total concentration Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 for each electrolyte divided by the length of mechanical ventilation. Data were compared using the Wilcoxon test. Results The higher TV group was ventilated with a TV of 890 ± 251 ml and a plateau pressure of 31 ± 8 cmH2O while the lower TV group had a TV of 472 ± 262 ml (P = 0.006) and a plateau pressure of 17 ± 9 cmH2O (P = 0.02). The length of mechanical ventilation for the high TV group was 1,850 ± 633 minutes and for the low TV group was 3,341 ± 749 minutes (P = 0.0006). The urinary output for the high TV was 37 ± 16 ml/hour and for the low TV was 52 ± 19 ml/hour (P = 0.10). The high TV group showed lower urinary sodium (40 ± 35 mEq/l vs 93 ± 26 mEq/l, P = 0.007), higher urinary potassium (52 ± 12 mEq/l vs 35 ± 23 mEq/l, P = 0.04) and a lower urinary sodium/potassium ratio (0.77 ± 0.7 vs 3.86 ± 3.3, P = 0.001). Before TV was increased, urinary output, urinary concentrations of sodium, potassium and sodium/potassium ratio were not diferent. Conclusions Data show that injurious ventilation is sensed by the kidney as a relative hypovolemia with reduction in sodium urinary output, increased excretion of potassium and inverted sodium/potassium ratio. P524 Impact of positive luid balance on survival in critically ill cancer patients J Almeida, H Palomba, L Hajjar, V Torres, F Galas, M Ferreira, F Duarte, T Trielli, L Yu, J Otavio Heart Institute, São Paulo, Brazil Critical Care 2010, 14(Suppl 1):P524 (doi: 10.1186/cc8756) Introduction Fluid overload has recently been linked to adverse outcomes in critically ill patients, but its impact on the outcomes of cancer patients admitted to ICUs has not been previously described. The aim of this study is analyze the impact of luid overload on outcomes of patients with cancer needing intensive care. Methods A total of 122 cancer patients admitted to the medical ICU in a 6-month period were prospectively evaluated for survival. Univariate and multivariate analysis were used to study ICU admission parameters associated with ICU mortality. Exclusion criteria were ICU stay <24 hours and chronic renal failure on dialysis. Results Overall mortality was 15.5% (n = 19). The mean age of all patients was 62.7 ± 11.6 years and 55% (n = 68) were male. One hundred and six patients (86%) had solid tumors and 16 (14%) had hematologic malignancies. Postoperative care (49%) and sepsis (38%) were the major reasons for admission to the ICU. The mean APACHE II score value at ICU admission was 17.2 ± 6.4 and the mean Karnofsky score before ICU admission was 75.2 ± 17.2. At multivariate analysis, the following variables at ICU admission were signiicantly associated with ICU mortality in cancer patients: Lung Injury Score (LIS) >2 (OR 3.3; 95% CI 1.32 to 8.23) and positive luid balance (for each 100 ml/24 hours) (OR 1.03; 95% CI 1.01 to 1.06). Conclusions Fluid overload is independently associated with increased mortality in critically ill cancer patients. Further studies are necessary to determine the impact of positive luid balance on acute organ dysfunction and overall prognosis of cancer patients. References 1. 2. Bouchard J, et al.: Fluid accumulation and acute kidney injury: consequence or cause. Curr Opin Crit Care 2009, 15:509-513. Bouchard J, et al.: Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury. Kidney Int 2009, 76:422-427. P525 Fluid accumulation has an adverse efect on outcome of ICU patients with acute kidney injury M Ostermann, H Cole, R Beale Guy’s and St Thomas’ Foundation Hospital, London, UK Critical Care 2010, 14(Suppl 1):P525 (doi: 10.1186/cc8757) Introduction Management of acute kidney injury (AKI) is heterogeneous with little consensus about luid therapy, vasopressors and diuretics. The aim was to analyse whether luid management inluences outcome in critically ill patients with AKI. S176 Table 1 (abstract P525). Mean cumulative luid balance (SD) in ICU survivors and nonsurvivors Degree of AKI Survivors Nonsurvivors P value +2,527 ml (118) +3,694 ml (314) <0.0001 AKI II +4,348 ml (929) +6,896 ml (2,492) 0.0007 AKi III +3,228 ml (173) +4,780 ml (295) <0.0001 AKI I Methods Retrospective analysis of the data for 4,645 patients admitted to the multidisciplinary ICU at Guy’s and St Thomas’ Foundation Hospital between April 2004 and June 2009. AKI was deined according to the AKI network criteria, which distinguish between three diferent grades of AKI. Maximum degree of AKI and total cumulative luid balance between ICU admission and the day of AKI were recorded. Results A total of 1,225 patients (26.4%) had AKI I, 29 patients (0.6%) had AKI II and 1,183 patients (25.5%) had AKI III of whom 89% were treated with renal replacement therapy. Two hundred and thirty-seven (5.1%) patients had end-stage dialysis-dependent renal failure and 1,971 patients (42.4%) had no AKI during their stay in the ICU. The ICU mortality was 15.6% in AKI I, 17.2% in AKI II and 34.9% in patients with AKI III (AKI I vs AKI III: P <0.0001). Cumulative luid balance at diagnosis of AKI was signiicantly higher in patients who later died (Table 1). Conclusions There is a correlation between luid accumulation on the day of AKI and subsequent ICU outcome. Among patients with any degree of AKI, nonsurvivors had a higher cumulative luid balance compared with ICU survivors. Future analysis needs to determine whether luid accumulation was the cause of worse outcome, the result of more aggressive resuscitation or a marker of more severe AKI. P526 Signiicant microalbuminuria, on admission to the ICU, may indicate AKI in patients with sepsis S Basu1, M Bhattacharya1, T Chatterjee2, S Todi1, A Majumdar1 1 AMRI Hospitals, Kolkata, India; 2Jadavpur University, Kolkata, India Critical Care 2010, 14(Suppl 1):P526 (doi: 10.1186/cc8758) Introduction In sepsis, a generalised inlammatory onslaught causes systemic endothelial dysfunction; the glomerular manifestation of which is microalbuminuria. Recent histopathological evidence of extensive glomerular capillary iniltration by leucocytes in septic AKI suggests that endothelial dysfunction may play a particularly important role in this condition compared with patients with other causes of AKI. Markers of endothelial dysfunction such as microalbuminuria may therefore have a potential diagnostic role in septic AKI. Methods Prospective observational study in a 20-bed ICU in a tertiarycare hospital. Microalbuminuria estimated as the spot urine albumin– creatinine ratio (ACR, mg/g) was measured on ICU admission. Two hundred and sixty-six patients were recruited between January 2007 and December 2008. Patients with an ICU stay of less than 24 hours, pregnancy, menstruation, anuria, hematuria, proteinuria due to renal and post-renal structural diseases were excluded. Sepsis was diagnosed by the ACCP/ SCCM criteria; AKI was identiied on admission using the RIFLE criteria. Results Of the 266 patients studied, 130 patients had no AKI while 136 patients had AKI as classiied by the RIFLE criteria. Of these 136 patients, 59 patients were in the Risk category, 62 in the Injury and 15 patients in the Failure, of which 26 patients (9.8%) needed RRT. For the entire cohort, median age was 61.5 years, 61% were male, median APACHE II score was 15. Of these, 56 (21%) of patients died on the ICU. ACR showed signiicant correlation with serum creatinine values (P = 0.0049, Spearman rank correlation (r) = 0.173) and was negatively associated with estimated GFR (P = 0.0002, r = –0.225). The median level of ACR (204.1 mg/g, (IQR 119.7 to 402.0)) of patients with septic AKI (n = 66) on admission to the ICU was signiicantly greater (P <0.0001) than the median ACR level of 67.1 mg/g (IQR 32.99 to 129.9) of patients who had AKI from other causes (n = 70). Patients of sepsis who had developed AKI also had higher ACR than those who did not (n = 51) (ACR 119.3 mg/g (IQR 37.02 to 354.3)) (P = 0.0137). Conclusions Presence of signiicant microalbuminuria on admission to the ITU may be an early indicator of AKI in sepsis patients. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P527 Neutrophil gelatinase-associated lipocalin as an early indicator for postoperative renal failure CD Van der Marel, H De Geus, J Bakker ErasmusMC, Rotterdam, the Netherlands Critical Care 2010, 14(Suppl 1):P527 (doi: 10.1186/cc8759) Introduction Neutrophil gelatinase-associated lipocalin plasma (pNGAL) and urine (uNGAL) concentrations can be used as early indicators for the development of acute kidney injury (AKI) [1]. As AKI is associated with higher risk of morbidity and mortality in ICU patients [2], higher pNGAL and uNGAL on admission might be relevant to the clinical course. No data on pNGAL and uNGAL as early indicators of postoperative AKI have been published. Methods We collected plasma and urine samples from patients admitted postoperatively following noncardiopulmonary bypass-related surgery. NGAL concentrations were measured using an immunoluorescence assay. Subsequently we compared the time points of maximum pNGAL, uNGAL and SCr concentrations in the group of patients developing postoperative AKI (Mann–Whitney U test). Data are presented as mean ± SD. Results One hundred and ninety-ive consecutive patients (age: 58 ± 16 years; APACHE II 15 ± 6) were included. Twenty-two patients (age 63 ± 17; APACHE II 20 ± 7) developed AKI (AKI 1 n = 14; AKI 2 n = 3; AKI 3 n = 5). Time to reach peak (Tmax) concentrations for pNGAL, uNGAL and SCr are respectively 21 (21), 20 (22), 31 (32) for AKI 1, 39 (32), 24 (31), 54 (12) for AKI 2, and 17 (18), 26 (24), 34 (27) for AKI 3. Maximum concentrations of pNGAL (ng/ml), uNGAL (ng/ml) and SCr (mmol/l) are respectively 1,348 (1,569), 364 (220), 147 (38) for AKI 1, 424 (309), 949 (389), 175 (28) for AKI 2, and 2,375 (1,731), 726 (398), 265 (81). Figure 1 shows time course of pNGAL and uNGAL in patients developing AKI. Tmax of pNGAL and uNGAL was signiicantly earlier than Tmax of SCr (both α <0.001). Figure 1 (abstract P527). Conclusions In postoperative patients developing AKI, pNGAL and uNGAL reach peak concentrations 1 day earlier than SCr. This might be of clinical importance as it provides us with an opportunity to prevent further deterioration of renal function at an earlier stage. References 1. 2. Mishra J: Lancet 2005, 365:1231-1238. Metnitz PG: Crit Care Med 2002, 30:2051-2058. P528 Neutrophil gelatinase-associated lipocalin as an early indicator for mortality in adult critically ill patients with acute kidney injury WP Ridder, H De Geus, J Bakker Erasmus MC, Rotterdam, the Netherlands Critical Care 2010, 14(Suppl 1):P528 (doi: 10.1186/cc8760) Introduction Neutrophil gelatinase-associated lipocalin (NGAL) measured in plasma or urine has shown to be an excellent early predictor for the development of acute kidney injury (AKI) [1]. Furthermore, AKI is an independent risk factor for mortality in critically ill patients [2]. We therefore hypothesized that NGAL concentrations measured at ICU admission in plasma and urine are associated with mortality. Methods We collected plasma and urine samples at ICU admission from all consecutive admitted patients (n = 700), of whom 171 during their S177 irst week of admittance, meeting criteria for any stage of AKI according to RIFLE classiication for serum creatinine (sCr) increase only. NGAL concentrations were measured using a rapid immunoluorescence assay (Triage® meter plus; Biosite Inc., San Diego, CA, USA). The Mann–Whitney U test was used for comparison of mean NGAL concentrations in plasma and urine between survivors and nonsurvivors. Exclusion criteria were patients with a history of nephrectomy, chronic or end-stage renal disease, kidney transplant surgery and informed consent refusal (n = 36). Results One hundred and seventy-one patients met criteria for AKI and were included in the statistical analysis. Median (25th to 75th percentile) age (years), APACHE II score after 24 hours and on admission sCr concentrations for survivors (n = 105) and nonsurvivors (n = 66) were respectively 59 (46 to 68) and 64 (53 to 73), 21 (15 to 26) and 26 (22 to 31), and 65 (60 to 80) and 80 (65 to 100) μmol/l. Median (25th to 75th percentile) NGAL plasma and urine concentrations were respectively 300 (160 to 504) ng/ml and 426 (127 to 1,543) ng/ml for the survivors and 457 (281 to 991) ng/ml and 1,189 (381 to 4,124) ng/ml for the nonsurvivors. These diferences for both plasma and urine NGAL values were statistically signiicant (both P <0.005). Conclusions Plasma and urine NGAL concentrations at ICU admission are signiicantly higher in nonsurviving patients compared with concentrations in surviving patients. Therefore NGAL measured at admission might be an early indicator for mortality. References 1. 2. Mishra J: Lancet 2005, 365:1231-1238. Metnitz PG: Crit Care Med 2002, 30:2051-2058. P529 Urinary and plasma NGAL levels relect the severity of acute kidney injury K Bangert, LO Uttenthal BioPorto Diagnostics A/S, Gentofte, Denmark Critical Care 2010, 14(Suppl 1):P529 (doi: 10.1186/cc8761) Introduction NGAL levels are dramatically increased in urine and plasma from patients with acute kidney injury (AKI). In this study we tested the clinical utility of NGAL in critically ill patients with many confounding conditions including sepsis. In addition, a new fully automated NGAL assay was validated with a selection of clinical samples from these patients. Methods Plasma and urinary NGAL was monitored (daily to alternate days) in 135 consecutive patients admitted to intensive care. AKI was classiied according to the RIFLE criteria. Three patients were excluded because of incomplete data. NGAL was determined with an ELISA kit (BioPorto Diagnostics). Diferences between maximal NGAL levels in the patient were analyzed nonparametrically by the Kruskal–Wallis test. Data are reported as median (interquartile range) in ng/ml. A fully automated immunoturbidimetric NGAL test (The NGAL Test; BioPorto Diagnostics) was tested. The NGAL Test was validated by means of linearity studies with dilutions of calibrator material, determination of antigen excess zone and a method comparison with the ELISA kit on 40 urine and 40 plasma samples with NGAL levels from 25 to 2,995 ng/ml as measured by ELISA. Results Sixty-two patients did not have AKI; 15 were classiied as risk (R), 11 as injury (I) and 44 as failure (F). The urinary NGAL was signiicantly (P <0.0001) higher in patients with AKI (R 377 (102 to 830), I 519 (321 to 1,845) and F 2,747 (559 to 7,621)) than in patients without AKI (51 (29 to 213)). Plasma NGAL levels were signiicantly (P <0.0001) higher in patients with AKI (R 354 (259 to 511), I 546 (331 to 1,106) and F 1,062 (584 to 1,817)) than in patients without AKI (199 (128 to 308)). Linearity studies of The NGAL Test demonstrated a measuring range from 25 to 5,000 ng/ml. No deleterious efect of antigen excess was seen up to a level of 40,000 ng/ml. There was good agreement between the ELISA and The NGAL Test results, the Pearson coeicient of correlation being 0.98 for both urine and plasma samples. Conclusions It is concluded that NGAL is dramatically increased in the urine and plasma of unselected critically ill patients with AKI and the degree of injury is relected by the observed levels despite several confounding conditions. NGAL determination may therefore be useful for the diagnosis of renal injury and monitoring the management of patients admitted to intensive care. Validation of The NGAL Test demonstrates a performance that complies with the expectations for a fully automated clinical laboratory assay, which can thus be a valuable tool for the management of critically ill patients. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P530 Economic impact and cost-efectiveness of urine neutrophil gelatinase-associated lipocalin following cardiac surgery A Shaw1, D Chalin2 1 Duke University Medical Center, Durham, NC, USA; 2Abbott Diagnostics, Abbott Park, IL, USA Critical Care 2010, 14(Suppl 1):P530 (doi: 10.1186/cc8762) Introduction Acute kidney injury (AKI) is common after cardiac surgery and recognition with speciic biomarkers may improve outcome. We assessed the impact and cost-efectiveness (CE) of urine neutrophil gelatinase-associated lipocalin (uNGAL) for AKI diagnosis compared with current methods. Methods We developed a decision analysis model to evaluate the CE of uNGAL plus standard diagnostic tests (for example, BUN, creatinine) compared with standard methods alone. The model was developed from the UK societal using costs per quality-adjusted life years (QALY). Model parameters were derived from the literature, UK economic data, and MD interviews. The base case was a 68-year-old male patient undergoing coronary artery bypass surgery. Sensitivity analyses were performed to determine how CE would vary with changes in the underlying model variables. Results The base case yielded expected costs of £4,244 and 11.86 QALYs for NGAL compared with £4,672 and 11.79 QALYs without NGAL. The CE ratio for the NGAL strategy was £358/QALY compared with £396/QALY for the standard regimen. CE increased as treatment efect – deined as the ability to prevent AKI progression (Injury or Failure) – for the therapy triggered by an elevated NGAL level rose. Sensitivity analysis showed that the model was most responsive to the probability of developing AKI and least sensitive to the cost of the NGAL test. Probabilistic sensitivity analysis demonstrated that the NGAL strategy was the more cost-efective option at a willingness-to-pay threshold of £30,000/QALY for each of the 1,000 simulations (Figure 1). Conclusions Use of uNGAL appears to be cost-efective in the diagnosis of AKI after cardiac surgery. S178 in patients after cardiac surgery and not enough information about its usefulness in critically ill patients exists. To analyze the predictive value of plasma NGAL to predict AKI, evaluated by RIFLE score, in critically ill patients, particularly in those with severe sepsis and septic shock. Methods NGAL was measured in whole-blood (Triage® NGAL Test; Inverness Medical, UK) at admission and after 48 hours in patients admitted to a general ICU. Patients were classiied according to RIFLE score at admission and 24 and 48 hours thereafter and according to NGAL concentrations at admission using values suggested by Constatin and colleagues [2] (≤155 or >155 ng/ml). NGAL values at admission were compared in patients under systemic inlammatory response syndrome (SIRS), severe sepsis and septic shock. Results Sixty patients were included (28 female) with mean age 58 ± 18.6 years, SAPS II 40.6 ± 15.7, SOFA 6.9 ± 3.9, length of ICU stay of 11.4 ± 11.1 days and mortality of 23%. Forty patients developed SIRS, six severe sepsis and 14 septic shock. Eleven patients developed AKI (RIFLE F), 10 of them at ICU admission; extracorporeal renal therapies were required in six cases. Thirty patients have NGAL ≤155 ng/ml. When patients were classiied according to RIFLE score at 24 hours of admission, NGAL values at admission were 180 ± 170 ng/ml in 36 patients with RIFLE 0, 243 ± 317 ng/ml in seven patients with RIFLE R, 303 ± 134 ng/ml in four patients with RIFLE I and 536 ± 421 ng/ml in nine patients with RIFLE F (P = 0.003). One patient was discharged before 24 hours (NGAL<60 ng/ml); whereas three patients who died before 24 hours had NGAL at admission of 578 ± 350 ng/ml. The area under the ROC curve of NGAL at admission for the prediction of AKI was 0.83 (95% conidence interval 0.70 to 0.97, P = 0.001), with an optimal cutof value of 277 ng/ml with 73% sensitivity and 77% speciicity. NGAL concentrations at admission were 160 ± 159 ng/ml in 40 patients with SIRS, 335 ± 206 ng/ml in six patients with severe sepsis and 540 ± 347 ng/ml in 14 patients with septic shock (P <0.001). Conclusions Plasma NGAL concentrations measured at ICU admission appeared a useful predictor of AKI in critically ill patients; in addition, NGAL concentrations showed an increasing pattern from SIRS to severe sepsis and septic shock. References 1. 2. Misra J, et al.: Lancet 2005, 365:1231. Constantin JM, et al.: J Crit Care 2009, in press. P532 Study of serum vancomycin levels in diferent modalities of hemodialysis in Indian patients C Sarkar, A Majumdar, S Todi AMRI Hospitals, Kolkata, India Critical Care 2010, 14(Suppl 1):P532 (doi: 10.1186/cc8764) Figure 1 (abstract P530). Probabilistic sensitivity analysis of incremental CE of NGAL vs standard methods. P531 Neutrophil gelatinase-associated lipocalin predicts acute kidney injury in critically ill patients K Núñez, J Baldirà, M Cuartero, H Aguirre, M Rodríguez, P Vera, LL Zapata, A Roglan, J Ordóñez, AJ Betbesé Hospital de la Santa Creu i Sant Pau, Barcelona, Spain Critical Care 2010, 14(Suppl 1):P531 (doi: 10.1186/cc8763) Introduction Plasma and urinary concentrations of neutrophil gelatinaseassociated lipocalin (NGAL) are early biomarkers of acute kidney injury (AKI) [1]. Most studies about the NGAL value to predict AKI were done Introduction To evaluate the vancomycin trough level in patients on intermittent hemodialysis (IHD), slow low-eiciency dialysis (SLED) and continuous renal replacement therapy (CRRT) and to assess the appropriateness of an improvised protocol, which is to repeat the vancomycin dose (15 mg/ kg) after 5 days on IHD, after 3 days on SLED and after 2 days in CRRT. Methods This study was conducted at AMRI Hospitals, Kolkata between November 2008 and April 2009. Thirty-three patients were studied. Fifteen were on IHD, 15 were receiving SLED and three were on CRRT. Mean age for the IHD group was 56.09 ± 11.4, for SLED was 64.3 ± 13.4, and for CRRT was 68 ± 8.34. The male:female ratio was 2:1 for IHD, 1.5: 1 for SLED and 2:1 for CRRT. Patients with severe hepatic impairment, obesity, cystic ibrosis and neoplastic disorder were excluded from this study. The mean Charlson score was 3.6 ± 4.8 for the IHD group, 5.26 ± 1.16 for SLED and 8.6 ± 11.2 for CRRT, respectively. High-performance liquid chromatography was used for assay of vancomycin. Results The mean vancomycin trough levels were 18 ± 3.99 on day 5 for patients on IHD, 15.3 ± 4.1 on day 3 for patients on SLED and 11.9 ± 2.4 for patients on CRRT. This prospective observational study is unique, in the sense that data are sparse regarding vancomycin levels, on various modalities of hemodialysis. The second and more important observation from this study was that our improvised dosing of vancomycin needs revision, since, of the patients on dialysis, 80% (12/15) of patients on IHD and 60% (9/15) of patients on SLED had higher than the recommended trough level (15 μg/ml), whereas for patients on CRRT the trough levels were subtherapeutic at 30 hours. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Conclusions This pilot study underscores the need for more awareness, mandatory checking of vancomycin trough levels and a larger study in Indian patients to deinitively determine dosage guidelines in this ethnic population. P533 RIFLE criteria for acute kidney dysfunction following liver transplantation: incidence and risk factors A Kundakci, A Pirat, O Komurcu, A Torgay, H Karakayalı, G Arslan, M Haberal Baskent University Hospital, Ankara, Turkey Critical Care 2010, 14(Suppl 1):P533 (doi: 10.1186/cc8765) Introduction Acute renal dysfunction (ARD) is one of the most common complications of orthotopic liver transplantation (OLT), with an incidence ranging from 12 to 64% [1,2]. These patients are often critically ill in the perioperative period with a number of other co-morbidities, resulting in an increased susceptibility to ARD. The RIFLE criteria were developed to provide a consensus deinition for acute renal dysfunction in critically ill patients. Using the RIFLE criteria, we aimed to determine the incidence and risk factors for acute renal dysfunction in the early postoperative period. Methods The records of 112 patients who underwent OLT, performed by the same team in the Baskent University Hospital, from January 2000 to February 2009, were retrospectively analyzed. Three levels of renal dysfunction, outlined in the RIFLE criteria, were investigated. Collected data included demographic features; co-morbidities; etiology of the liver failure; perioperative laboratory values; intraoperative hemodynamic parameters; use and volume of crystalloids, colloids, blood products, cell saver system, and albumin; portal vein clamping time; requirement for inotropes, vasopressors, and antihypertensive drugs; duration of anesthesia; and urine output. Results ARD occurred in 64 of OLTs (57%). Risk, injury, and failure frequencies were 19%, 11%, and 28%, respectively. Compared with those who did not have ARD postoperatively, those who did had signiicantly higher MELD scores (19 ± 7 vs 16 ± 8; P = 0.018), more frequently required inotropic agents intraoperatively (54% vs 35%; P = 0.070), received more colloids (300 ± 433 ml vs 105 ± 203 ml; P = 0.007), had a longer portal vein clamping time (88.0 ± 42.0 minutes vs 73.0 ± 20.0 minutes; P = 0.037), and had a higher incidence of intraoperative acidosis (64% vs 44%; P = 0.047). Logistic regression analysis was performed using these data to ind the predictors for development of ARD. ARD was found to be associated with MELD score (odds ratio 1.107, 95% CI 1.022 to 1.200, P = 0.013), portal vein clamping time (odds ratio 1.020 95% CI 1.000 to 1.040, P = 0.053) and intraoperative acidosis (odds ratio 3.610, 95% CI 1.212 to 10.753 P = 0.021). Conclusions Based on RIFLE criteria, more than one-half of the patients who underwent liver transplantation developed ARD postoperatively. A higher MELD score, longer portal vein clamping time, and occurrence of intraoperative acidosis were identiied as the independent risk factors for development of ARD in this group of patients. P534 Prophylactic use of laxative for constipation in critically ill patients Y Masri, J Abu Baker, R Ahmed Rashid Hospital Trauma Center, Dubai, United Arab Emirates Critical Care 2010, 14(Suppl 1):P534 (doi: 10.1186/cc8766) Introduction The aim of this study was to evaluate the use of laxative prophylaxis for constipation in the ICU and the impact of early versus late bowel movement on patient outcome. Methods After informed consent, all adults in the ICU who were expected to stay on a ventilator for >72 hours were randomized to Control and Interventional groups. Patients who had major bowel surgery were excluded. The Control group did not receive any intervention for bowel movement for the irst 72 hours, while the Interventional group received a prophylactic dose of Lactulose 20 cc orally every 12 hours for the irst 72 hours. After 72 hours the management of constipation in the both groups was left to the physician’s discretion. Data were collected for age, sex, diagnosis, Simpliied Acute Physiology Score (SAPS) II, doses of narcotics and sedatives, enteral nutrition, ventilator days, ICU days, bowel movement <72 hours and days of irst bowel movement. S179 Results Over a 6-month period a total of 100 patients were enrolled, 50 patients in each Control and Interventional group. Mean age was 38.8 years in Control and 37.5 years in Interventional group. Both groups had a predominance of male patients. The most common diagnosis in both groups was polytrauma. Mean SAPS II for both was 35. One hundred percent of patients were ventilated, with a mean dose of fentanyl (323.8 ± 108.89 μg/hour in Control and 345.83 ± 94.43 μg/hour in Interventional group) and a mean dose of midazolam (11.1 ± 4.04 mg/hour in Control and 12.4 ± 3.19 mg/hour in Interventional group). Enteral nutrition was maintained and tolerated by 100% of patients. There were only two (4%) patients in the Control group and nine (18%) patients in the Interventional group who had bowel movement in <72 hours (P <0.05). Twenty-three (46%) patients in the Control and 29 (58%) patients in the Interventional group had bowel movement after 5 days. Mean ventilator days were 16.19 and 17.36 days in the Control and Interventional groups. Subgroup analysis showed that the patients who moved their bowel in <5 days in both groups had mean ventilator days of 18.5, while it was 15.88 days for the patients who moved their bowel after 5 days in both groups (P <0.05). Forty-eight (96%) patients in each group were discharged from the ICU. Mean ICU days for the Control group was 21.15 ± 10.44 and was 20.77 ± 8.33 days for the Interventional group. A total of two (4%) patients died in each group. Conclusions Laxative prophylaxis can be used successfully to prevent constipation in ICU patients. Late bowel movement >5 days is associated with less ventilator days, compared with early <5 days bowel movement. P535 Study of intra-abdominal hypertension in the medical intensive care unit P Theerawit Ramathibodi Hospital, Bangkok, Thailand Critical Care 2010, 14(Suppl 1):P535 (doi: 10.1186/cc8767) Introduction Intra-abdominal hypertension (IAH) is associated with signiicant mortality in surgical and trauma patients. However, IAH can occur in medical patients as well. Thus, the main objective of this study was to assess whether the IAH during the irst 24-hour period of admission was an independent predictor for 28-day mortality. Methods We conducted a prospective observational study. All patients admitted to the medical ICU were enrolled in this study and underwent intra-abdominal pressure (IAP) measurement via the bladder. The primary outcome was the association between IAH and 28-day mortality rate. Results Seventy-seven eligible patients were enrolled to this study. The incidence of IAH was 44%. The mean age was 60.52 ± 18.34 years. In terms of 28-day mortality, there was no association between the presence of IAH and mortality outcome. However, regarding ICU mortality, nonsurvivors had signiicantly higher mean IAP within 24 hours of admission than survivors: 11.55 (8.0 to 20.3) vs 9.95 (3.0 to 27.0) (P = 0.041). Conclusions Neither the mean IAP nor the presence of IAH within the irst 24 hours of admission was an independent predictor for 28-day mortality. Nonetheless, this study demonstrated the diference of IAP between survivors and nonsurvivors in terms of ICU mortality in the medical ICU. References 1. 2. 3. 4. 5. Malbrain ML, Cheatham ML, Kirkpatrick A, et al.: Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. I. Deinitions. Intensive Care Med 2006, 32:1722-1732. Malbrain ML, Chiumello D, Pelosi P, et al.: Incidence and prognosis of intraabdominal hypertension in a mixed population of critically ill patients: a multiple-center epidemiological study. Crit Care Med 2005, 33:315-322. Malbrain ML, Chiumello D, Pelosi P, et al.: Prevalence of intra-abdominal hypertension in critically ill patients: a multicentre epidemiological study. Intensive Care Med 2004, 30: 822-829. Malbrain ML: Abdominal pressure in the critically ill: measurement and clinical relevance. Intensive Care Med 1999, 25:1453-1458. Gudmundsson FF, Viste A, Gislason H, Svanes K: Comparison of diferent methods for measuring intra-abdominal pressure. Intensive Care Med 2002, 28: 509-514. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P536 Intra-abdominal pressure values of emergency department intensive care unit patients and clinical outcomes O Demirci, S Girisgin, B Cander, E Dogan, D Dündar Selcuk University Meram Faculty of Medicine, Konya, Turkey Critical Care 2010, 14(Suppl 1):P536 (doi: 10.1186/cc8768) Introduction Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have become serious causes of morbidity and mortality in critical surgical and medical patients, especially in the past 10 years. Increased IAP levels became one of the routine physiologic parameter measurement elements in critical patients and indicate prognosis. In this study, our aim was to observe IAP increase, APB decrease and their clinical manifestations in ICU patients. Methods Eighty-nine ICU patients were included in this study. IAP levels were measured by infusing 25 ml saline into the urinary bladder. The symphisis pubis plane ailiated as the zero point. Patients were divided into groups according to IAP and APB levels. Clinical follow-up, required medical care and survival were investigated. Results Within the 89 patients, 36 of them diagnosed as IAH and 34 of them diagnosed as low APB. There were 25 patients that had both IAH and low APB. In these patients, during the irst 2 days of the study, statistically signiicant SGOT, SGPT, PO2, urea and creatinine levels were found. We also determined increased positive inotropic support and ventilatory support need with increased sepsis and multiple organ failure incidence in these patients. Mortality rates were strongly related to IAH and low APB levels. Conclusions In critically ill patients, IAP measurement, a very simple and valuable method, must be performed. IAH and low APB levels are indicators of high morbidity and mortality rates. Therefore, IAP measurement may become a routine element in follow-ups and survival rate determinations, in critically ill patients. References 1. 2. 3. Cheatham M, Malbrain M: Cardiovascular implications of abdominal compartment syndrome. Acta Clin Belg Suppl 2007, 1:98-112. Cheatham M, Malbrain M: Intra-abdominal hypetension and the cardiovascular system. In Abdominal Compartment Syndrome. Edited by Ivatury R, Cheatham M, Malbrain M, Sugrue M. Georgetown, TX: Landes Biosciences; 2006:89-104. Malbrain ML, De laet I: Functional haemodynamics during intraabdominal hypertension: what to use and what not use. Acta Anaesthesiol Scand 2008, 52:576-577. P537 Advanced haemodynamic assessment of patients with liver disease and abdominal compartment syndrome D Joshi, S Saha, W Bernal, J Wendon, G Auzinger King’s College Hospital, London, UK Critical Care 2010, 14(Suppl 1):P537 (doi: 10.1186/cc8769) Introduction Intra-abdominal hypertension (IAH, >12 mmHg) and abdominal compartment syndrome (ACS, >20 mmHg) frequently complicate the disease course in critically ill patients with liver disease. There is a paucity of data describing the circulatory changes observed during ACS outside experimental studies. The aim of this study was to investigate baseline haemodynamic variables in patients with ACS and their response following abdominal decompression. Methods Patients admitted to the liver ICU of King’s College Hospital with ACS were studied. Transpulmonary thermodilution cardiac output monitoring and calculation of volumetric indices of preload was performed with the PiCCO system. MAP, CVP, ITBVI, cardiac index (CI), stroke volume index (SVI) and intraabdominal pressure (IAP) were analysed pre and post intervention. Results Eighteen patients (nine female), median age 43 (range (R) 20 to 65) were studied. Ten patients had decompensated Budd–Chiari syndrome (BCS), eight underwent orthotopic liver transplantation and two had surgical shunt procedures. Eight patients had cirrhosis (PC) with organ failure and severe ascites necessitating therapeutic paracentesis. Pre-intervention IAP was raised (median 24, R 17 to 40). As a whole, volumetric markers of pre-load were low (median ITBVI 674, R 453 to 1,619) but improved (median ITBVI 763, R 512 to 1,110) post intervention (P = 0.02). Reduction in CVP post intervention was not statistically signiicant (16, R 0 to 25 vs 14, R 5 to 29). Compared with the PC group, the BCS S180 group had persistently low ITBVI (median 633, R 453 to 924) despite aggressive volume resuscitation prior to decompression (median positive luid balance 10 l, R 0.5 to 39). Abdominal decompression resulted in a reduction in IAP (median 15, R 6 to 31, P <0.0001), increase in preload (ITBVI) and improvement in CI (3.9, R 1.9 to 7.4 vs 4.6, R 2.7 to 7.7, P <0.0001) and SVI (40, R 22 to 111 vs 44, 30 to 61, P = 0.001). There was an inverse relationship between IAP, CI (P = 0.003) and SVI (P = 0.004). ITBVI correlated with parameters of low (CI P <0.0001 and SVI P <0.0001), CVP did not. Conclusions ACS leads to central hypovolaemia. Abdominal decompression restores preload in association with improvement in cardiac output. References 1. 2. Cheatham et al.: Intensive Care Med 2007, 33:951-962. Malbrain et al.: Intensive Care Med 2006, 32:1722-1732. P538 Molecular adsorbent recirculating system in hepatic failure patients with a ventricular assist device M Cristinar, J Thiranos, H Kremer, C Chalumeau, J Mazzucotelli Nouvel Hopital Civil, Strasbourg, France Critical Care 2010, 14(Suppl 1):P538 (doi: 10.1186/cc8770) Introduction The study we performed focuses on the removal of bilirubin in hepatic failure patients with a ventricular assist device (VAD). Bilirubin is a risk factor revealing the severe hepatic insuiciency and the alteration of the clinical status. The mortality rate of patients developing liver failure in the cardiac ICU is very high. The molecular adsorbent recirculating system (MARS) is the hepatic failure treatment in patients with no other therapeutic options. It is a liver support system that uses an albuminenriched dialysate to facilitate the removal of albumin-bound toxins. Conventional hemodialysis techniques have little or no efect on liver detoxication and cannot improve these patients’ prognosis. The study aims to prove the decrease of the mortality rate in hepatic failure patients with VAD as a result of using MARS. Methods We conducted a retrospective study of 55 patients with VAD. They were hospitalized in our cardiac ICU between January 2000 and November 2009. All patients had a hepatic check-up when admitted to the ICU. The patients with altered liver function had at least one checkup per day. We had seven patients with hyperbilirubinaemia >350 μmol/l (the threshold for starting hepatic dialysis). Five patients received MARS therapy. Hepatic check-ups were performed at the beginning and at the end of the session. Results Five patients were dialysed. Patient 1 – with a maximum serum bilirubin level of 350 μmol/l, needed four cycles of MARS therapy; the patient survived. Patient 2 – max bilirubin 390 μmol/l, 6 MARS; the patient survived. Patient 3 – max bilirubin 700 μmol/l, 3 MARS; the patient did not survive. Patient 4 – max bilirubin 680 μmol/l, 3 MARS; the patient survived. Patient 5 – max bilirubin 500 μmol/l, 15 MARS; the patient did not survive. The two patients that did not receive MARS therapy did not survive. Conclusions MARS is a viable option for the treatment of hepatic failure patients and, in particular, for those with VAD. We consider that without MARS a VAD patient cannot survive if his serum bilirubin level exceeds 350 μmol/l. Our hypothesis needs to be conirmed by multicenter randomized trials. References 1. 2. Saliba F, et al.: The Molecular Adsorbent Recirculating System (MARS) in the intensive care unit: a rescue therapy for patients with hepatic failure. Crit Care 2006, 10:118. El-Banayosy A, et al.: Evaluation of MARS technique on patients sufering from hypoxic liver failure following cardiogenic shock. ASAIO J 2002, 48:139. P539 Molecular adsorbent recirculating system in patients with acute liver failure: prospective follow-up D Tran-Zweifel, B Goubaux, L Bornard, J Dellamonica, M Carles, O Perus, M Raucoules Hopital de l’Archet II – CHU de Nice, France Critical Care 2010, 14(Suppl 1):P539 (doi: 10.1186/cc8771) Introduction A prospective observational study on molecular adsorbent recirculating system (MARS) therapy in a liver-disease-dedicated ICU. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Methods From January 2004 to November 2009, all patients with an acute liver failure fulilling MARS therapy criteria, in relation to two main indications: primary and secondary to chronic liver failure (ALF/ACLF = group 1) or intractable pruritus (IP = group 2), were included: Data were collected before and after each MARS procedure. APACHE and MELD scores [1] were used to predict the ICU mortality and the 90-day mortality, respectively. Results Thirty-nine patients, APACHE II = 41 (21 to 86); MELD = 29 (14 to 47), having received 98 treatments (one to ive treatments), were included. The overall mortality was n = 22 (56%). Since 35 patients have been treated for ALF/ACLF, 15 underwent a liver transplantation (OLT) (see Figure 1). The 90-day mortality of the 20 patients from group 1 without OLT was 44%, compared with 76% predicted by the MELD score. MARS was efective to decrease the bilirubin levels –35% (of the pretreatment rate which was 30 times the baseline), P <0.01, the ammoniemia levels –50% (of the pretreatment rate which was four times the baseline), P <0.01, and serum creatinine levels –40% (of the pretreatment rate which was two times the baseline). The MARS therapy was also efective to improve the pruritus after two treatments in the group 2 patients. A single severe complication was noticed as hemorrhagic shock quickly resolved in one patient (group 1). S181 20 months (November 2007 to June 2009). All ICU admissions were screened for cirrhosis. Clinical data were recorded to calculate and evaluate several critical illness and disease-speciic scoring systems (APACHE II, SAPS II, SOFA, Child Pugh (CPS), MELD, UKELD, Glasgow Alcoholic Hepatitis Score and the Royal Free Hospital (RFH) score). Study endpoints were ICU and hospital mortality. Results Cirrhosis accounted for 3.3% (137/4,198) of ICU admissions. In 118 patients meeting inclusion criteria, ICU and hospital mortality rates were 38% and 47%. Median (IQR) age was 50 (43 to 59) years, 68% were male, median length of ICU stay was 4.5 (2 to 10) days and 72% had alcoholic cirrhosis. Median CPS was 10 (8 to 11) (45% Grade A/B), MELD 18 (12 to 24) and APACHE II 16 (13 to 22). Hospital mortality was 24% in CPS grade B and 66% in grade C. After multivariate analysis, factors independently predictive of mortality were bilirubin, INR, urea, bicarbonate and pO2/ FiO2 ratio. AUROC for the scoring systems ranged from 0.76 (UKELD) to 0.81 (RFH) for the prediction of mortality. Renal failure (OR 3.4 (1.4 to 8.4)) and haemoiltration during admission (OR 9.6 (3.7 to 24.8)) had strong associations with mortality. Intubation for gastrointestinal bleeding OR 0.4 (0.1 to 1.3) was associated with a trend towards better outcome than intubation for respiratory failure OR 2.7 (1.0 to 7.0). Conclusions The mortality rates and disease stage reported here are lower than those described in the established literature. Data from specialist transplant centres should not be applied to the patient cohorts seen in general ICUs. We urge critical care physicians to carefully consider the individual clinical case when deciding on ICU admission and not apply potentially misrepresentative igures from previous datasets. P541 Acute liver failure: a European perspective J Wendon1, W Bernal1, P Laterre2, F Nevens3, M Hudson4, M Aldersly3, D Mutimer5, N Murphy5, A Burroughs6, J O’Bierne6, V Arroyo7, Y Ilan8, G Lalazar8, K Simpson9, M Manns10, J Hadem10, F Larsen11 1 King’s College Hospital, London, UK; 2St Luc University Hospital, Brussels, Belgium; 3St James Hospital, Leeds, UK; 4University of Newcastle, UK; 5 University of Birmingham, UK; 6Royal Free Hospital, London, UK; 7University of Barcelona, Spain; 8Hebrew University Hadassah Hospital, Jerusalem, Israel; 9 Royal Inirmary Hospital, Edinburgh, UK; 10University of Hannover, Germany; 11 Rigshospital, Copenhagen, Denmark Critical Care 2010, 14(Suppl 1):P541 (doi: 10.1186/cc8773) Figure 1 (abstract P539). Three-month outcome. Conclusions MARS therapy improves liver function in patients with both acute and chronic liver failure, and allows those patients to wait until OLT, if necessary. Furthermore it also improves the 90-day survival of patients with ACLF having no OLT indication. References 1. Hepatology 2001, 33:464-470. P540 A study of patients with cirrhosis admitted to nontransplant general intensive care in the UK: prevalence, case mix, outcomes and evaluation of critical illness and disease-speciic scoring systems SJ Thomson1, C Moran1, ML Cowan1, S Musa1, R Beale2, D Treacher2, M Hamilton1, M Grounds1, TM Rahman1 1 St George’s Hospital, London, UK; 2St Thomas’ Hospital, London, UK Critical Care 2010, 14(Suppl 1):P540 (doi: 10.1186/cc8772) Introduction Hospital admission rates attributable to cirrhosis are increasing in the UK. The evidence base for the outcome of critically ill patients with cirrhosis admitted to intensive care (ICU) is currently limited to data from tertiary transplant centres, which report mortality rates of between 45 and 74%. We hypothesised that the disease cohort experienced in secondary care is less severe than that reported in the literature and would subsequently demonstrate lower mortality. We report the prevalence, case mix and outcomes of a dual-centre ICU study in London, UK. Methods Data were collected prospectively from two large nontransplant general ICUs in London (St George’s and St Thomas’ Hospitals) over Introduction Acute liver failure (ALF) is a rare disease with a spectrum of presentations from mild coagulopathy and altered conscious level to multiple organ failure and intracranial hypertension (ICH). A new group, Acute Liver Failure studies in Europe (ALSiE), has and wishes to further initiate collaboration between centres with clinical expertise in the management of ALF. It aims to establish a pan-European database of clinical and demographic data in ALF and initiate clinical studies. Methods We describe the experience of 13 centres in seven countries over a 3-month period to 31 March 2009. ALF was deined as an INR >1.5 and encephalopathy in the absence of chronic liver disease. Results are presented as median and IQ range. Results Eighty-ive patients were treated, acetaminophen was the dominant aetiology in the UK, 60%, and represented 34% in other centres. At presentation INR was 3.8 (2.1 to 6.5), hepatic encephalopathy (HE) grade I (0 to 2) was observed and 20% required pressors. Grade III/IV coma was seen in 64% during their course and of these 25% developed ICH. Seventyone per cent required ventilation, 58% renal replacement therapy and pressors in 65%. Ninety per cent required management in a critical care environment. Overall survival was 75% – 42 cases fulilled poor prognostic criteria (PPC), of whom 31 were transplanted, 28 (90%) surviving to hospital discharge. Of the 11 remaining, four survived and seven died. Thirty-two out of 43 who did not fulill PPC survived. Patients who died were older and had a predominant aetiology of hypoxic hepatitis. One organ support or less was associated with 70% survival with medical management alone. Two organ support or more was required in 55 patients and 27% survived with medical management, the remainder requiring transplantation or died. Conclusions ALF has a high prevalence of progression to multiple organ failure requiring a multidisciplinary approach (critical care, transplant surgery and hepatology) to achieve optimal outcome. The development of ICH is 25% in grade III/IV HE. Despite this, outcomes are good. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P542 Intracranial pressure monitoring in acute liver failure: a review of 10 years experience M Peck, J Wendon, E Sizer, G Auzinger, W Bernal King’s College Hospital, London, UK Critical Care 2010, 14(Suppl 1):P542 (doi: 10.1186/cc8774) Introduction Intracranial hypertension (ICH) complicates around 25% of grade III/IV encephalopathy in acute liver failure. Intracranial pressure (ICP) monitoring is controversial in this coagulopathic population. Methods We examined the ITU charts and prospectively maintained an ITU database of all patients admitted with acute liver failure who underwent ICP monitoring from December 1998 to December 2008. Data are presented as median and range. Results One hundred and ifteen patients were identiied. Aetiology was acetaminophen (78), seronegative (14), drug induced (7), viral (14) and autoimmune (two). All patients had a Camino ICP bolt (subdural) inserted by the intensive care specialist. Coagulation support fresh frozen plasma (10 ml/kg) and platelets if the count was <100 were given. Recombinant factors were not given. Overall 66 survived and 49 died. Seventy patients underwent transplantation with 77% survival. Age was 31 (24 to 42), International Normalised Ratio (INR) 5.6 (3.9 to 9.2), creatinine 150 μmol/l (105 to 143), Na 139 (135 to 143). INR pre insertion of the bolt was 3.5 (2.2 to 7.3), platelets 109 (51 to 137). At bolt insertion, pulse was 100 (89 to 111), MAP 80 (72 to 89), ICP 19.5 (12 to 25), CO2 4.8 (4.3 to 5.5), lactate 3.5 (2.2 to 5.3), jugular venous saturation 76 (67 to 84), temperature 35.5 (34.8 to 36.4). Norepinephrine dose was 0.12 μg/kg/minute (0.02 to 0.4). ICP fell to 14 (9 to 19) at 6 hours and 13 (8 to 20) at 24 hours. Peak ICP was 30 (20 to 39), number of surges >20 per patient was 2 (0 to 7). Minimum cerebral perfusion pressure (CPP) was 45 (38 to 52). The pre-liver-transplant peak ICP was 27 (19 to 35), post was 23 (20 to 33). There were no correlates between clinical parameters, ICP or CPP at 0, 6, 12 or 24 hours. No diference in insertion ICP and CPP was found between groups. Sixteen patients had postmortem examination. Cerebral oedema was noted in seven, and in two there was evidence of an intracerebral bleed, fronto-parietal region (bolt site). Fifteen underwent CT scanning – of whom three had evidence of difuse ischemia, oedema and tentorial herniation. One case had a small fronto-parietal bleed (survived). Mode of death was cerebral in 14 cases. In those who had a CPP <45 46% survived, whilst in those with a CPP >45 66% survived. Conclusions ICP monitoring is a relatively safe procedure in this high-risk cohort of patients. Three ICP bolt-related complications were observed, two died and one survived. In those who survived there were no clinically apparent neurological sequelae. Mortality is increased in those with CPP <45 but is not inevitable and should not preclude transplantation and/or aggressive medical management. P543 Microdialysis catheters in liver transplants detect vascular complications and rejection HH Haugaa, TI Tønnessen Oslo University Hospital, Oslo, Norway Critical Care 2010, 14(Suppl 1):P543 (doi: 10.1186/cc8775) Introduction Following liver transplantation, hepatic artery stenosis and portal vein obstruction occur in 3 to 12% of the patients, and more frequently in children than adults. Today, the standard of care is Doppler ultrasound and liver enzyme assessment daily. Accordingly, detection of severe hypoperfusion may be delayed. The aim of the present study was to explore whether microdialysis catheters implanted in the left and right liver lobe, by measurement of glucose, lactate, pyruvate and glycerol every 2 hours, detected vascular complications and rejection. Methods Seventy-three patients undergoing 82 liver transplantations were included. Nine of the patients were children. Two microdialysis catheters were inserted in the liver and one in subcutaneous tissue by a split needle technique. They were kept for as long as the catheters functioned, and maximally 4 weeks. Metabolic parameters (glucose, pyruvate, glycerol and lactate) were collected every 2 hours and measured bedside. Results Median age of the patients was 52 years (6 months to 70 years). The median time for catheters inserted in the liver was 9.5 days, with a range from 0.5 to 26 days. Six patients had hepatic artery stenosis/ S182 occlusion, and in ive of them lactate increased to values >10 mM with a lactate/pyruvate ratio of several hundred and a concomitant decrease in glucose and increase in glycerol. In one patient (a 6-month-old child) lactate only increased to 2 mM and the LP ratio to 20. On the background of pathological metabolic values, all patients underwent immediate reoperation and blood clots were removed and the artery reanastomosed. In the child with low lactate values, the low of the artery was less than 10% of total hepatic blood low, despite reanastomosis. Thus, the exceptionally high portal low delivered enough oxygen to prevent major ischemia despite very low low in the artery. Thirteen patients had rejection veriied by biopsy, and in six patients anti-rejection therapy was given based on liver function tests and clinical judgement. All patients had some increase in lactate during the period of rejection, but the increase was in all but four patients only 1 mM. In the remaining four the increase was 3 to 4 mM. Conclusions By using microdialysis catheters measuring metabolic parameters, hepatic artery occlusions can be detected very rapidly. Patients with rejection show a small, but signiicant, increase in lactate. P544 Drug-induced hepatic cholestasis in the ICU: a case–control study D Williamson1, M Bédard Dufresne2, V Bonhomme3, M Albert1, C Verdant1, AJ Frenette1 1 Hôpital du Sacré-Coeur de Montréal, Canada; 2Centre Hospitalier HonoreMercier, St-Hyacinthe, Canada; 3Hopital Maisonneuve-Rosemont, Montreal, Canada Critical Care 2010, 14(Suppl 1):P544 (doi: 10.1186/cc8776) Introduction Liver dysfunction in critically ill patients represents a major concern. Many drugs used in the ICU have been associated with hepatotoxicity. Hepatotoxicity presents in three distinct patterns: cholestatic (alkaline phosphatase (AP) ≥2 x ULN and ratio (ALT/ULN)/(AP/ ULN) ≤2), hepatocellular (ALT ≥3 x ULN and ratio ≥5) and mixed (AP ≥2 x ULN, ALT ≥3 x ULN and ratio between 2 and 5). No published studies have assessed the drug-induced cholestastic pattern of hepatotoxicity in the ICU. The aim of this study was to assess whether use of pharmacological classes previously associated with cholestasis are associated with an increased risk of pure or mixed cholestasis in the ICU. Methods A nested case–control study assessed the potential association between use of speciied pharmacological classes and cholestasis. Cases were identiied from a cohort of patients admitted ≥24 hours in whom at least one value of AP <240 IU/l had been obtained in the 72 hours following admission. We excluded patients with an identiied cause of cholestasis as well as patients with bone metastasis and pregnant women. Each case the subject was matched to a control subject based on age, gender, and length of ICU stay and admission year. Exposure to antiepileptics, penicillins, cephalosporins, carbapenems, macrolid antibiotics and parenteral nutrition was collected and included in a multivariate conditional logistic regression analysis with known risk factors. Results A total of 113 patients developed cholestasis between May 2001 and March 2009, of which 95 had no identiied cause. We matched 95 cases with 95 controls and controlled for APACHE II score, sepsis, obesity, diabetes, length of stay and prior history of cholestasis. In multivariate logistic regression, parenteral nutrition (OR 6.26), sepsis (OR 4.05), and penicillins (OR 3.97) were independently associated with cholestasis. Conclusions Cholestasis in the ICU often remains of unknown origin. In our study, sepsis, parenteral nutrition and penicillins were independently associated with the development of cholestasis in patients admitted to the ICU. P545 Diagnosis of acute cholecystitis in septic patients A Ioakimidou, M Moykas, A Theodotou, A Amygdalou, C Catsenos, K Mandragos Korgialenio-Benakio Red Cross Hospital, Athens, Greece Critical Care 2010, 14(Suppl 1):P545 (doi: 10.1186/cc8777) Introduction The aim of this retrospective observational study was to evaluate the usefulness of clinical, laboratory and imaging indings in the diagnosis of acute cholecystitis (AC) in septic patients. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Methods Twelve out of 1,248 patients were included in the study. The patients had no intra-abdominal pathology on admission. Mean age was 59.08 (16.14) years. The most common ICU admission diagnosis was trauma (7/12). On admission, mean APACHIE II score was 17.916 (5.74) and SOFA score was 8.083 (3.369). On the day of diagnosis, SOFA score was 13 (4.03). Mean length of stay in the ICU before the diagnosis was 32.35 (13.76) days. Diagnosis was based on clinical, laboratory, U/S and C/T criteria. Conirmation of the diagnosis was performed with an operative procedure: open cholecystectomy (n = 8), laparoscopy (n = 2), percutaneous cholecystostomy (n = 2). Results Twelve of 1,248 patients (0.96%) developed clinical, laboratory and imaging indings of AC. The AC was conirmed by an operative procedure in eight out of 12 patients (0.64%), one calculus and seven acalculus. The mortality was 62.5%. Necrotic areas of the gallbladder wall existed in three patients. Clinical diagnostic indings were: tenderness in the right upper quadrant of the abdomen and positive Murphy in 16.66%; temperatures over 38.5°C in 50%; leucocytosis in 58.33%; metabolic acidosis in 50%; elevation of ALT in 50% and AST in 66.66%; bilirubin >1.17 mg/dl in 91.66%; and an increase of alkaline phosphatase in 100% of patients with conirmed AC. There was one false negative 8% and three false positive 75% and one true negative 25% ultrasonography. The most common U/S inding was gallbladder distention (n = 8) 66.66% and sludge (n = 8) 66.66%. Respectively, there were two false negative 25% and two false positive 50% C/T scans. Two patients underwent diagnostics laparoscopies that were true negative. Conclusions There is not a speciic diagnostic test for AC in trauma septic patients. Laparoscopy at the bedside in the ICU is an accurate and safe diagnostic tool. Reference 1. Laurila et al.: Acta Anaesthesiol Scand 2006, 50:173-179. P546 Bleeding and pneumonia in intensive care unit patients given PPIs and H2RAs for prevention of stress ulcer: a metaanalysis J Zhou, X Wan, L Han First Ailiated Hospital of Dalian Medical University, Dalian, China Critical Care 2010, 14(Suppl 1):P546 (doi: 10.1186/cc8778) Introduction To assess the eicacy and safety of proton pump inhibitor and histamine-2 receptor antagonist in ICU patients for stress ulcer prophylaxis. Methods Trials were identiied by performing a systematic search of MEDLINE, Ebsco and CNKI. Two reviewers assessed the quality of studies and extracted data independently. Disagreement was resolved by discussion. Revman 4.2.2 software developed by the Cochrane collaboration was used for meta-analysis. Results Four trials involving 771 patients were included. Meta-analyses showed that the incidence of clinically important bleeding was signiicantly lower in the PPI group as compared with H2RA (OR 0.45, 95% CI (0.21, 0.9), P = 0.04). The incidence of nosocomial pneumonia (OR 1.03, 95% CI (0.63, 1.70), P = 0.89) and mortality (OR 1.17, 95% CI (0.76, 1.80), P = 0.47) had no signiicant diference. Conclusions In comparison with H2RA, PPI is more efective in the prevention of stress ulcer bleeding (SUB) in patients in intensive care. There Figure 1 (abstract P546). PPIs vs H2RAs: bleeding rate. S183 Figure 2 (abstract P546). PPIs vs H2RAs: rate of nosocomial pneumonia. is no signiicant diference in the incidence of nosocomial pneumonia and mortality between the two groups. Because the randomized controlled trials are few and these indings are based on a small number of patients, irm conclusions cannot presently be proposed. More randomized, multicenter studies with suicient sample size should be performed. Reference 1. Stollman N, Metz DC: Pathophysiology and prophylaxis of stress ulcer in intensive care unit patients. J Crit Care 2005, 20:35-45. P547 Inluence of septic shock on energy expenditure in critically ill ICU patients, estimated with indirect calorimetry R Włodarski1, K Kusza2 1 Military Clinical Hospital, Bydgoszcz, Poland; 2University of Nicolaus Copernicus, Collegium Medicum of Ludwik Rydygier, Bydgoszcz, Poland Critical Care 2010, 14(Suppl 1):P547 (doi: 10.1186/cc8779) Introduction Energy requirements of critically ill septic shock patients treated in the ICU are particularly diicult to determine. Recent research shows that energy expenditure (EE) in those patients may be smaller than it was previously believed. EE values in this group are afected by the severity of the disease process as well as by administered treatment (sedation, inactivity of skeletal and respiratory muscles, ighting fever). The purpose of this study was to establish the inluence of septic shock on EE in sedated and mechanically ventilated patients treated in the ICU. Using indirect calorimetry, we assessed EE in those patients and compared results with basal energy expenditure calculated according to the Harris– Benedict equation (BEE), and with EE values in patients subjected to general anesthesia. Methods Two groups of patients were studied with regard to EE measured by means of indirect calorimetry. Group I consisted of 50 critically ill patients treated in the ICU for septic shock. They were evaluated using the APACHE II and SOFA scores, taking into account the 28-day mortality. EE was measured continuously over the irst 24 hours of treatment by means of the Datex-Ohmeda M-COVX indirect calorimeter. Group II comprised 50 patients (ASA I and II), whose energy expenditure was measured under general anesthesia in surgical treatment of disc herniation. Energy expenditure measurements were taken with the use of the Datex-Ohmeda E-CAiOVX indirect calorimeter, adapted to work in an atmosphere containing anesthetic gases. Results The mean EE value measured with a calorimeter (CEE) in septic shock patients (CEE group I) was 1,467 ± 304 kcal/day or 20 ± 4 kcal/kg/ day. Their mean APACHE II score was 30.2, SOFA was 10.8. CEE in group I amounted to 67 to 137% of BEE (mean 101% of BEE) and to 121% of average CEE in anesthetized patients (CEE group II). Statistical dependence between mortality and CEE was demonstrated. CEE in surviving patients (APACHE: 26.8, SOFA: 8.1) amounted to 91 to 137% of BEE (mean 114% of BEE) and to 139% of average CEE in group II. CEE in deceased patients (APACHE: 32.9, SOFA: 13) amounted to 67 to 121% of BEE (mean 94% of BEE) and to 111% of average CEE in group II. Conclusions A decrease in the total metabolic rate of patients with severe sepsis and septic shock can constitute a prognostic indicator of heightened death risk in this group of ICU-treated patients. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P548 Evaluation of a novel motility capsule for gastric emptying in a porcine model of acute lung injury S Rauch, RM Muellenbach, A Johannes, B Zollhoefer, N Roewer University Wuerzburg, Germany Critical Care 2010, 14(Suppl 1):P548 (doi: 10.1186/cc8780) Introduction The aim of this study was to evaluate a novel wireless motility capsule for gastric emptying in a large animal model of acute lung injury. Methods All experimental procedures were approved by the Laboratory Animal Care and Use Committee of the District of Unterfranken, Germany and adhere to the NIH guidelines for ethical animal research. In seven anesthesized pigs, ventilated with high-frequency oscillation, a pH, pressure and temperature sensing capsule (SmartPill™; SmartPill Corp., Bufalo, NY, USA) was positioned with a capsule delivery device (AdvanCE™; US Endoscopy, Mentor, OH, USA) into the stomach. The capsule data were transmitted to a recorder attached to the abdomen. Gastric emptying of the capsule can be calculated by measuring the time required for the pH to the change from the acidic stomach to the alkaline duodenum as well as a change in pressure patterns. The location of the capsule was conirmed by autopsy after the animals had died due to the ARDS. Results In total 8,640 datasets were obtained. The capsule pressure recordings ranged from 2 to 4 mmHg (2.6 ± 0.5 mmHg (mean ± SD)) and pH ranged from 2.3 to 5.6 (3.7 ± 1.6 (mean ± SD)). There was no change in pressure patterns or pH recordings greater than 6 during 24 hours. All animals had a gastroparesis with bloated stomach. All capsules were located in the stomach as indicated by the pressure and pH data and conirmed by autopsy. Conclusions The preliminary data show that motility capsule technology has considerable potential for evaluating real-time gastric emptying. P549 Preliminary results on the validation of a novel method for measuring intra-abdominal pressure and gastric residual volume M Malbrain1, R Tepaske2, J Valtysson3, P Palmers1, A Van Ingelgem1, N Van Regenmortel1, I De laet1, K Schoonheydt1, H Dits1 1 ZNA Stuivenberg, Antwerpen, Belgium; 2Academic Medical Centre, Amsterdam, the Netherlands; 3Akademiska Sjukhuset, Uppsala, Sweden Critical Care 2010, 14(Suppl 1):P549 (doi: 10.1186/cc8781) Introduction This study will look at the validation of a novel method combining measurement of gastric residual volume (GRV) and estimation of intra-abdominal pressure (IAP) via intragastric pressure (IGP). Methods In total 88 paired IAP and GRV measurements were performed in the HOB position in 23 mechanically ventilated ICU patients. The IAP was estimated by the height of the urine column via the bladder (that is, IBP) using the FoleyManometer (Holtech Medical, Charlottenlund, Denmark) and via the stomach (that is, IGP) with the new device (Gastro PV; Holtech Medical). The GRV was measured with the new device (GRVprototype) and via the classic method (GRVclassic). The male-to-female ratio was 2:1, age 62.3 ± 18.8 (range 22 to 86), BMI 25.3 ± 6.2 (16.6 to 40.4), APACHE II score 21.3 ± 4.1 (13 to 30), SAPS II score 50.7 ± 13.2 (17 to 83), and SOFA score 10.1 ± 2.8 (6 to 17). The number of measurements in each patient was four (except one patient with ive, one patient with one and one patient with two measurements). Statistical analysis was done with SPSS-13 software, values are expressed as mean ± SD or median (and range). Results The mean IBP was 11.3 ± 4 and mean IGP was 11.7 ± 3.9. Correlation between the IBP and IGP was signiicant but moderate (R2 = 0.37). Analysis according to Bland and Altman showed a bias and precision of 0.5 and 3 mmHg, respectively; however, the limits of agreement were large and ranged from –5.4 to 6.4 mmHg. The median GRVprototype was 100 ml (0 to 1,050) and median GRVclassic was also 100 ml (0 to 1,250). Correlation between the two methods was excellent (R2 = 0.89). Analysis according to Bland and Altman showed a bias and precision of –1.3 and 59.2 ml, respectively, and the limits of agreement ranged from –117 to 114 mmHg. The median drainage time and return times were 3.1 minutes (0.5 to 15) and 2 minutes (0 to 21) for GRVprototype compared with 2 minutes (0.1 to 9) and 1 minute (0 to 8) for GRVclassic. Conclusions The preliminary results of an ongoing multicentre pilot study show that the gastro PV is a good alternative to the standard S184 method for measuring GRV. Because the nurse can perform other tasks during drainage and return of the GRV, and the fact that the system remains closed during measurement, this could be a major step forward in standardisation of GRV measurement. Furthermore it allows screening for intra-abdominal hypertension via IGP estimation. Acknowledgements The gastro PV devices were provided by Holtech Medical, free of charge. P550 Monitoring enteral nutrition eicacy in ICU patients: is there a place for the Brix value-derived fraction of enteral formula in gastric residual volume? JS Stuer, M Casaer, D Lerouge, J Helderweirt, N Nijs, G Van den Berghe, I Vanhorebeek UZ Leuven, Belgium Critical Care 2010, 14(Suppl 1):P550 (doi: 10.1186/cc8782) Introduction Achieving nutritional targets by means of enteral nutrition in critically ill (ICU) patients has been shown to be diicult and unpredictable. In this regard, the amount of enteral formula lost in gastric residual volume (GRV) remains unknown. In previous studies performed in a non-ICU population, bedside monitoring of the speciic gravity (or relative density) of GRV with a refractometer (expressed as Brix value) has been shown to be an accurate tool to measure the concentration of enteral nutrition (% EF) in GRV [1,2]. The aim of this study is to evaluate the use of the Brix value in monitoring the concentration of enteral feeding in GRV of patients in the ICU. Methods The speciic gravity, pH and clinical aspect of GRV in fasting ICU patients were examined. The Brix value of gastric luid from fasting critically ill patients was measured with a refractometer. One observer measured the Brix value of each sample in duplo. A third measurement was performed by an independent observer. The enteral nutrition was diluted in GRV in vitro to establish the relation between measured Brix value and % EF by linear regression analysis. Factors inluencing the measured Brix value were analyzed in a linear regression analysis. Results The mean ± SD Brix value for GRV of 51 fasting ICU patients was 2.9 ± 1.1 (ranging from 0.0 to 6.0). The inter-observer and intra-observer variabilities were 8.4 and 3.2%. The relation between Brix value and % EF was signiicantly afected by gastric luid pH before mixing with nutrition. Analyzing all measurements with simple linear regression revealed the following linear relation (P <0.0001): % EF = (Brix value – 2.368/0.185). Conclusions The hand-held refractometer is a good tool for monitoring the overall nutritional eicacy in an enteral nutrition strategy measuring and discarding GRV. The linear relation between % EF in GRV and measured Brix value described in earlier non-ICU studies was conirmed in ICU patients. However, the large baseline Brix variation in ICU patients and unpredictable impact of the pH of GRV makes the Brix value less suitable for the management of nutrition in individual patients. References 1. 2. Chang et al.: Clin Nutr 2005, 24:760-767. Chang et al.: Clin Nutr 2004, 23:105-112. P551 Initial gastric volume, nasogastric tube and pneumonia incidence in trauma patients N Libert1, E Pons-ukkola2, T Leclerc2, P Clapson2, B Debien2, JP Perez2 1 HIA Val de Grâce, Paris, France; 2HIA Percy, Clamart, France Critical Care 2010, 14(Suppl 1):P551 (doi: 10.1186/cc8783) Introduction Gastric emptying is often delayed in major trauma patients. These patients are at risk of regurgitation and aspiration during rapid sequence induction or during coma. We hypothesized that an early nasogastric tube (NGT) would reduce the gastric residuals. We also checked whether gastric volume at admission was associated with aspiration pneumonia. Methods Data from consecutive trauma patients that underwent a full body CT scan from January 2006 to August 2009 were retrospectively analyzed. Gastric gas, liquid/solid and total volume were measured using 3D contouring on the CT scan performed at admission. Secondarily referred trauma patients and patients hospitalized for less than 24 hours Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 were excluded from the study. Onset time and occurrence of pneumonia were extracted from the hospital’s database; patients who died during the irst 48 hours were then excluded. Patients staying for 2 days or longer in the ICU were divided into two groups (with or without NGT) and analyzed separately. Results One hundred and ifty-six patients were analyzed. CT scan showed a NGT in 30 patients (one malposition in the medium esophagus). Gastric gas, liquid/solid and total volume were not diferent in patients with and without NGT (Z test; gas: 54 ± 147 vs 95 ± 168 ml, P = 0.179; liquid/solid: 226 ± 282 vs 199 ± 237, P = 0.626; Total: 280 ± 311 vs 295 ± 320, P = 0.824). Twenty out of 153 patients developed a pneumonia in the irst 7 days, ive of which with NGT and 15 without (chi-squared, P = 0.459). There was no diference in gastric residuals between these patients and the 133 others (Mann–Whitney; Q1-median-Q3; Gas: 11-25-126 vs 14-43-90 ml, P = 1; liquid/solid: 16-63-432 vs 22-115-290 ml, P = 0.799; Total: 29-252661 vs 68-186-371 ml, P = 0.873). Seventy-three patients were admitted to the ICU, of which 23 had a NGT and 20 developed pneumonia. There was no diference between gastric residuals of the 23 who had a NGT and the 50 others. A pneumonia developed in the irst 3 days in 1/23 patients with NGT vs 9/50 without NGT (chi-squared–Yates, P = 0.226); in the irst 7 days in 5/23 patients with NGT vs 15/50 without NGT (chi-squared, P = 0.462). There was no diference in gastric residuals between patients who developed early pneumonia (at 3 and 7 irst days) and those who did not. There was no diference in ICU length of stay (10.8 vs 12.7 days, P = 0.825) and onset time of pneumonia (4.2 vs 3.3 days, P = 0.234). Conclusions Our results suggest that gastric volume is high at admission of trauma patients, irrespective of NGT presence. In this study, pneumonia incidence was related neither with high gastric volume, nor with NGT usage. P552 Achieving nutritional targets in the ICU V Gopal, S Hutchinson Norfolk and Norwich University Hospital, Norwich, UK Critical Care 2010, 14(Suppl 1):P552 (doi: 10.1186/cc8784) Introduction McWhirter and Pennington stated in 1994 that 40% of patients are malnourished on admission to hospital [1]. Malnutrition increases morbidity and mortality in the ICU. Early feeding improves outcome, length of stay and septic complications. Methods We aimed to assess the standard of nutritional practice, and measure caloric achievement and caloric debt in the irst 7 days of admission of critically ill patients. The European Society of Parenteral and Enteral Nutrition guidelines on enteral nutrition are set as the standard [2]. Between April and August 2009, all adult patients not fed orally within 3 days of admission to the ICU were included. The caloric target was 25 kcal/kg/day. All impediments to achievement of feeding targets were recorded. Results Among 30 patients (16 surgical and 14 medical), 11 patients were fed early within 24 hours of admission, 19 patients were fed 24 hours after admission. Twenty-three patients were fed by nasogastric tube, three patients received small bowel feeding. Parenteral nutrition (PN) was used Figure 1 (abstract P552). x axis: day since admission. y axis: percentage caloric target achieved. S185 alone in two patients and as a supplement to enteral nutrition (EN) in one patient. Conclusions Mean caloric achievement by day 7 was only 58.4% (Figure 1), well below target. The following recommendations have now been made to improve the nutritional practice. A higher threshold for residual gastric volumes has been adopted, an earlier aggressive use of prokinetic agents is recommended, strategies to access small bowel feeding earlier and PN is now considered within 24 hours if EN is contraindicated or as supplement to EN if the caloric target is not reached after 48 hours. References 1. 2. McWhirter JP, Pennington CR: BMJ 1994, 308:945-948. Kreymann KG, et al.: Clin Nutr 2006, 25:210. P553 Evaluation of studies of nutritional support team: 2 years’ experience A Ozcan, N Ozcan, T Cakan, C Kaymak, H Basar Ankara Training and Research Hospital, Ankara, Turkey Critical Care 2010, 14(Suppl 1):P553 (doi: 10.1186/cc8785) Introduction Nutritional screening and nutritional support have an important role to prevent malnutrition, which afects the prognosis and increases the morbidity and mortality of patients. We aimed to assess the patients who are consulted and followed by the nutritional support team during a 2-year period retrospectively. Methods Demographic characteristics, subjective global assessment scores (SGA) of patients’ type, route, duration of nutritional support and complications were assessed. Results A total of 379 patients were consulted during the 2-year period. Two hundred and two of them (53.3%) were male and 177 (46.7%) were female and the mean value of ages was 63.5 ± 17.9 years (7 to 96 years, minimum to maximum). SGA scores were A in 35.1% (n = 133), B in 26.6% (n = 101), and C in 38.3% (n = 145). In 31.9% (n = 121) of the patients combined parenteral and enteral, in 29.6% (n = 112) only parenteral, in 25.6% (n = 97) only enteral and in 12.9% (n = 49) oral nutritional support were administered. Combined parenteral and enteral nutritional support was applied via nasogastric tube and peripheral parenteral in 54.5% (n = 66), nasogastric tube and santral parenteral in 29.8% (n = 36), oral and santral in 5.8% (n = 7), oral and peripheral parenteral in 6.6% (n = 8), nasojejunal and peripheral parenteral in 1.7% (n = 2) and gastrostomy and peripheral parenteral in 21.7% (n = 2). Parenteral nutritional support was applied via peripheral route in 62.5% (n = 70) and santral route in 37.5% (n = 42). Enteral nutrition was commonly applied by nasogastric tube in 87.6% (n = 85) and gastrostomy tube in 10.3% (n = 10). Nutritional support was applied during 18.2 ± 23.7 days (1 to 306 days). The most common complications were constipation (7.4%), nasogastric tube displacement or obstruction (5.2%), diarrhea (2.6%), thrombophlebitis (3.4%), aspiration (1.8%) and hyperglycemia (1.6%). Conclusions Nutritional screening should be a component of physical examination in hospital and outpatients. P554 Are we feeding our critically ill patients appropriately? N Ramakrishnan, S Bhuvaneshwari, R Venkataraman, B Abraham Apollo Hospitals, Chennai, India Critical Care 2010, 14(Suppl 1):P554 (doi: 10.1186/cc8786) Introduction Nutrition plays a signiicant part in the overall treatment plan for critically ill patients. In India, there are varying practices including use of kitchen feeds and/or commercial formula and also predominant use of bolus feeds. The multidisciplinary team in our critical care unit (CCU) includes a senior dietician and we wanted to review whether our standardized practice of routine screening for malnutrition using subjective global assessment, early use of nutrition (preferably within 24 hours) and continuous enteral feeding using commercial formula helped achieve nutritional goals. Methods A retrospective chart review was conducted on 508 patients who received continuous enteral feeding on day 1 and day 5 of the ICU stay. Information on calories prescribed (using the Harris–Benedict equation) and delivered on day 1 and day 5 was collected. Achieving the nutritional goal was deined as successful delivery of 90% of prescribed Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S186 Table 1 (abstract P556). Comparison of patients with APACHE II scores 15 to 25 in the two groups Group n APACHE II scores LOS ICU (days) LOS hospital (days) Treatment cost (¥10,000) Mortality (%) Up to nutrition goal 28 17.58 ± 3.02 7.50 ± 3.94 8.42 ± 3.45 4.20 ± 3.49 0 Not up to nutrition goal 54 19.96 ± 2.97 13.11 ± 9.80* 28.63 ± 16.44* 9.42 ± 5.67* 14.8 *P <0.05. calories. Data were analyzed using SPSS software and standard statistical methods. Results On day 1, 37.6% of patients achieved delivery of caloric goals, and on day 5, this increased to 67.3%. Fluid restriction was the single most common reason for not meeting caloric goals both on days 1 and 5. Conclusions Despite the availability of a clinical dietician and standardized nutritional practice, compliance of achieving caloric goals is low. Commercial formulas with a maximum of 2 kcal/ml are available in India, unlike the West where more calorie-dense formulas (up to 4.5 to 5 kcal/ ml) are available. Availability of these higher calorie dense commercial formulas may help increase our rates of achieving nutritional goals as luid restriction appears to be the single most common limiting factor. P555 Efect of increased enteral nutrition on ICU-acquired infections: a multicenter observational study DK Heyland1, KE Stephens2, AG Day1, SA McClave3 1 Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Canada; 2Discovery Biometrics GlaxoSmithKline, Stevenage, UK; 3Department of Medicine, Louisville School of Medicine, Louisville, KY, USA Critical Care 2010, 14(Suppl 1):P555 (doi: 10.1186/cc8787) Introduction The objective of this study was to evaluate the efect of increasing enteral nutrition (EN) adequacy on acquired infection in the ICU. Methods Prospective, multicenter, observational study in three medical/ surgical ICUs. We enrolled consecutive patients within 24 hours of admission to the ICU who were expected to stay for more than 24 hours. For this analysis, we excluded patients who were not mechanically ventilated in the ICU for more than 72 hours and who received parenteral nutrition. No interventions. Charts were reviewed to determine nutritional adequacy and clinical outcomes. Suspected infections were adjudicated by two or more clinicians to determine the presence or absence of infection (rated as either probable or possible infection). Results A total of 598 patients were enrolled in the overall study; 206 were included in this analysis. The average patient age was 62.2 years; APACHE II score was 23.3; BMI 28.6; and 73% were medical. Overall, patients received 48.8% (range 0 to 120%) of their energy and 45.0% (range 0 to 120%) of their protein requirements from EN. On average, patients remained ventilated for 9.1 days (interquartile range (IQR) 6 to 11), in the ICU for 13.5 days (IQR, 7 to 14) and 25.2% and 21.8% developed an infection after 72 and 96 hours, respectively. Overall 28-day mortality was 29.1%. In the overall analysis, greater amounts of energy and protein were consistently associated with a reduction in infection but only achieved levels near statistical signiicance when considering the incremental efect of 1,000 kcal/day and 30 g/day on patients with at least one probable infection after >96 hours (odds ratio (OR) 0.32, 95% conidence interval (CI), 0.10 to 1.03, P = 0.055 and OR 0.41, 95% CI 0.19 to 0.89, P = 0.024 for energy and protein, respectively). In all cases, the OR was lower when considering infections that developed after 96 hours compared with infections that developed after 72 hours and when considering probable infections compared with all infections. There was a trend towards a reduction in pneumonia that developed after 96 hours with increasing amounts of energy (OR 0.40, 95% CI 0.10 to 1.53, P = 0.18) and protein (OR 0.42, 95% CI 0.16 to 1.09, P = 0.076). Conclusions Increased EN adequacy was associated with a reduction in infectious complication, particularly after 96 hours of ICU admission. P556 Impact of early enteral nutrition up to goal on the prognosis of patients with diferent severity of illness in the ICU L Fang, W Fang, L Liu Second Ailiated Hospital of Soochow University, Suzhou, Jiangsu, China Critical Care 2010, 14(Suppl 1):P556 (doi: 10.1186/cc8788) Introduction This study aimed to determine the value of early enteral nutrition up to goal on the prognosis of the patients with diferent severity of illness in the ICU. Methods A total of 192 critically ill patients who met the criteria for enrollment were included in this study during the past 18 months in our ICU. They were divided by grade as the severity of illness according to APACHE II scores. Retrospective analysis on early enteral nutrition checked whether the third day of enteral nutrition supply has reached the 60% nutrition goal (25 kcal/kg/day). So the patients were divided into two groups: up to goal and not up to goal. According to APACHE II scores, the patients were divided into three sub-groups with score inferior to 15, between 15 and 25 and superior to 25. Results When the scores of APACHE II were between 15 and 25, the LOS in the ICU (t = 3.966, P = 0.000), in hospital (t = 8.165, P = 0.000), the cost of medical care (t = 4.812, P = 0.000) and the mortality (t = 5.421, P = 0.038) were all signiicantly lower in patients with EEN up to goal. See Table 1. Conclusions The EEN up to goal can signiicantly increase the survival rate of critically ill patients, shorten the LOS in hospital and reduce the cost of medical care, when the patients have APACHE II scores between 15 and 25. The clinical value of EEN up to goal varies depending on the severity of illness. Reference 1. Nartindale RG, et al.: Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition: Executive Summary. Crit Care Med 2009, 37:1757-1761. P557 Beneit of supplemental parenteral nutrition in the critically ill patient? Results of a multicenter observational study DK Heyland1, NE Cahill1, M Wang1, J Kutsogiannis2, C Alberda3, L Gramlich2 1 Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Canada; 2University of Alberta, Edmonton, Alberta, Canada; 3Alberta Health Services, Edmonton, Alberta, Canada Critical Care 2010, 14(Suppl 1):P557 (doi: 10.1186/cc8789) Introduction Early enteral nutrition (EN) is the preferred strategy for feeding the critically ill; however, it is not always possible to achieve suicient calories and protein with EN alone. The use of supplemental parenteral nutrition (PN) has been advocated as a strategy to avoid complications associated with protein/calorie deicit from inadequate enteral feeding. The purpose of this study was to evaluate the efect of this practice on nutritional and clinical outcomes. Methods An international, observational study conducted in 2007 and again in 2008 examined nutrition practices in ICUs. Eligible patients were the mechanically ventilated who remained in the ICU for >72 hours and received early EN within 48 hours from admission. Data were collected on patient characteristics and daily nutrition practices for up to 12 days. Patient outcomes were recorded after 60 days. We compared the outcomes of patients who received early EN alone, early EN + early PN, and early EN + late PN (after 48 hours of admission). Regression analyses were conducted to determine the efect of increasing age, APACHE score, days in hospital prior to ICU admission, gastrointestinal dysfunction, nutritional strategy, and other baseline variables and their relationship to being alive and discharged within 60 days. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Results A total of 2,920 patients from 260 ICUs were eligible for this study; 2,562 (87.7%) in the Early EN group, 188 (6.4%) in the Early PN group, and 170 (5.8%) in the Late PN group. Adequacy of calories and protein was highest in the Early PN group (81.2% and 80.1%, respectively) and lowest in the Early EN group (63.4% and 59.3%) (P <0.0001). The 60-day mortality rate was 27.8% in the Early EN group, 34.6% in the Early PN group, and 35.3% in the Late PN group (P = 0.02). In a single predictor model, the proportion of patients discharged alive from hospital at 60 days was lower in the group that received Early PN (hazard ratio (HR) 0.75, 95% conidence interval (CI) 0.59 to 0.96) and Late PN (HR = 0.64, 95% CI 0.51 to 0.81) (P = 0.0003) compared with Early EN. These indings persisted after adjusting for known confounders. In subgroup analyses, we could not demonstrate any beneit to supplemental PN in patients with BMI <20. Conclusions The supplemental use of PN may improve provision of calories and protein but is not associated with any clinical beneit. P558 Role of iber diet formula in surgical critically ill septic patients K Chittawatanarat, P Pokawinpudisnun Chaing Mai University, Chiang Mai, Thailand Critical Care 2010, 14(Suppl 1):P558 (doi: 10.1186/cc8790) Introduction Diarrhea commonly occurs in surgical critically ill septic patients who received broad-spectrum antibiotics. Some reports demonstrated that a iber diet with prebiotic properties could decrease the risk of diarrhea in nonseptic patients. However, most reports excluded septic patients who received broad-spectrum antibiotics. The objective of this study was to compare risk of diarrhea and diarrhea score between iber and noniber diets in surgical septic patients who received broadspectrum antibiotics. Methods We conducted a prospective, randomized control, double-blind study on a general surgical ICU in a university hospital. The patients who received broad-spectrum antibiotics and no contraindication to enteral feeding were enrolled into two arms after informed consent. Allocation to intervention was randomized individually to receive iber diet or noniber diet up to 14 days. Demographic data, disease severity, nutritional delivery and diarrhea score were recorded each day. Intention-to-treat analysis was performed after completed study. Results Thirty-four patients were enrolled in the study (17 patients each in the iber group and the noniber group). These two patient groups were similar in demographics, disease severity, nutritional status, cause of sepsis and total feeding per day. Although the proportion of patients who confronted with diarrhea score >15 was higher in the noniber group than the iber group, these did not show statistical diference signiicantly (8/17 patients (47.06%) vs 4/17 patients (23.53%); P = 0.15). However; the group of the iber diet had a lower mean diarrhea score (iber vs noniber = 3.6 ± 2.3 vs 6.3 ± 3.6; P = 0.005) and the generalized estimation equation model for repeated measurement (GEE) revealed a lower global diarrhea score in the iber group than the noniber group about 3.03 (coeicient –3.03 (95% CI = –5.03 to –0.92); P = 0.005). Cox proportional hazard ratio of iber group was 0.45 (95% CI = 0.13 to 1.49; P = 0.19) but no statistical diference. Conclusions Enteral nutrition with a iber diet formula could reduce the diarrhea score in surgical critically ill septic patients who received broadspectrum antibiotics. P559 Efect of oral supplementation with immunonutrients on radiation-induced hematologic toxicity in cancer patients MC Calaguas St Luke’s Medical Center, Manila, Philippines Critical Care 2010, 14(Suppl 1):P559 (doi: 10.1186/cc8791) Introduction Radiation therapy in cancer patients causes hematologic abnormalities mainly attributed to an increased inlammatory state induced by radiation toxicity that are observed to be modulated by immunonutrition [1-3]. The objective of this study was to determine the efect of oral supplementation with immunonutrients on cancer patients undergoing radiation therapy on the following hematologic indices: hemoglobin, total WBC, neutrophil, lymphocyte, and platelet counts. S187 Methods Cancer patients on radiotherapy from 2007 to 2009 were randomly assigned to a study group (n = 24), which received standard diet plus oral supplementation with an immunonutrition regimen (= 200 ml drink given twice per day providing 600 kcal, 40 g protein, eicosapentanoic acid = 2 g, antioxidants (Vit A = 600 μg, Vit C = 75.2 mg, Vit E = 15 mg, B-carotene = 1,500 μg)), and a control group (n = 32), which only had standard diet. The hematologic data – hemoglobin, total WBC count, neutrophil count, lymphocyte count, and platelet count – were taken before and after completion of the prescribed radiation dose. The results were analyzed using either paired or independent-samples t test. Results In the study group the blood indices were higher compared with the control group at the end of radiation therapy: hemoglobin in gm% (12.8 >11.8, P = 0.002), total WBC (7,276 >4,877, P = 0.0005), and neutrophil count (5,363 >3,315, P = 0.0007). There were no diferences in the lymphocyte and platelet counts. The WBC change in the study group followed a decreasing pattern (–162.5) while in the control group it was an increasing pattern (+1,657). This indicated lesser inlammation in the study group while there was higher inlammation in the control group (P = 0.004). Conclusions Oral supplementation with immunonutrients in cancer patients undergoing radiation therapy resulted in lesser hematologic toxic changes in hemoglobin, total WBC, and neutrophil count. References 1. 2. 3. Mell LK, et al.: Int J Radiat Oncol Biol Phys 2008, 70:1431-1437. Suchner U, et al.: Proc Nutr Soc 2000, 59:553-563. Jho DH, et al.: Integr Cancer Ther 2004, 3:98-111. P560 Impact of multichamber bag parenteral nutrition (OliClinomel) upon inlammatory markers (EPICOS Study) A Pontes-Arruda1, L Martins1, S Lima1, M Pinheiro2 1 Hospital Fernandes Tavora, Fortaleza, Brazil; 2Laboratorio Evandro Pessoa, Fortaleza, Brazil Critical Care 2010, 14(Suppl 1):P560 (doi: 10.1186/cc8792) Introduction The use of a multichamber bag (MCB) as a way to deliver parenteral nutrition to critically ill patients has been associated by retrospective analysis with several beneits including lower bloodstream infection rates, and lower ICU stay [1]. This study aims to evaluate the efects of a MCT TPN system (considered a closed system) versus a conventional compounding system (COM, considered an open system) regardless of the type of lipid emulsion used. Methods Serum samples were collected in a prospective multicenter open label study (NCT#00798681) from 100 critical care patients receiving TPN with an olive oil-based lipid emulsion using either a premixed MCB and ready-to-use system (n = 50, OliClinomel; Baxter) or COM made either with an olive oil-based lipid emulsion (ClinOleic; Baxter) or with a LCT/MCT-based lipid emulsion (COM ClinOleic n = 25, COM LCT/MCT n = 25, total COM group n = 50). All samples were collected at baseline, day 4 and day 7 (three samples per time point). Changes in the levels of inlammatory markers from baseline to day 7 were compared using analysis of covariance and P <0.05 was considered statistically signiicant. Results At baseline, demographic characteristics of the patients were balanced between the groups. Regardless of the type of lipid used, critically ill patients receiving TPN using a MCB system presented at day 4 lower levels of: TNFα (3.4 vs 8.2 pg/ml), IL-6 (50.4 vs 62.0 pg/ml), IL-8 (56.4 vs 93.7 pg/ml), procalcitonin (PCT) (2.7 vs 7.6 ng/ml), lymphocyte externalization of phosphatidylserine (5.2 vs 9.6%), and resistin (9.1 vs 12.3 ng/ml) (all MCB vs COM and P <0.05). Statistically signiicant diferences were maintained throughout day 7. No diferences were observed for the levels of C-reactive protein and IL-10. Conclusions The administration of TPN using a MCB system led to a signiicant reduction in the inlammatory response when compared with COM, regardless of the type of lipid used. Particularly relevant are the diferences in terms of PCT as an early marker of sepsis since COM TPN was associated in previous studies with higher bloodstream infection rates [1]. Reference 1. Wischmeyer et al.: Crit Care Med 2009, 37(Suppl). Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P561 Efect of n-3 fatty acids on cerebral markers and the inlammatory response in sepsis CS Burkhart1, M Siegemund1, SP Strebel1, LA Steiner2 1 University Hospital Basel, Switzerland; 2CHUV et Université de Lausanne, Switzerland Critical Care 2010, 14(Suppl 1):P561 (doi: 10.1186/cc8793) Introduction Patients with sepsis are at high risk of developing sepsisassociated delirium (SAD), which is associated with increased mortality and may be an important risk factor for the development of long-term cognitive dysfunction. Mechanisms leading to SAD are unclear, therapy and prophylaxis unsatisfactory. Inlammation and its efects on the brain may play an important role. We hypothesized that n-3 fatty acids will have a beneicial efect on systemic inlammation and hence cerebral markers in sepsis. Methods Randomized single-blind design. Patients >18 years admitted for treatment of sepsis. Exclusion criteria were thrombocytopenia, brain injury or tumors, intracranial infection and history of stroke. Patients received treatment according to the Surviving Sepsis Campaign and were randomly allocated to a group with or without daily supplemental intravenous n-3 fatty acids (Omegaven™; Fresenius Kabi, 2 ml/kg/day). Daily screening for SAD was performed. CRP, IL-6, IL-8, S-100β, and neuronspeciic enolase (NSE) were monitored on days 1, 2, 3, and 7. The primary endpoint was the area under the curve of the S-100β time course. Results Eighteen patients were included. SAPS II scores and baseline values for CRP, IL-6, IL-8, NSE and S-100β for patients with and without supplemental n-3 fatty acids were 51 ± 14 vs 57 ± 22, 241 ± 65 vs 218 ± 106 mg/l, 2,054 ± 2,822 vs 734 ± 1,467 pg/ml, 312 ± 503 vs 90 ± 96 pg/ml, 25 ± 7 vs 21 ± 8 μg/ml, and 0.57 ± 0.90 vs 0.24 ± 0.24 μg/ml, respectively. In agreement with earlier data, patients with SAD had higher values for S-100β (P = 0.019) [1]. AUC for S-100β was 2.73 ± 2.89 vs 0.95 ± 0.74 (P = 0.14) for patients receiving supplemental n-3 fatty acids and controls, respectively. While none of the diferences reached signiicance, IL-6 and IL-8 declined more rapidly in the n-3 fatty acid-treated group whereas cerebral markers showed an opposite trend. The number of patients with SAD and the duration of SAD were not diferent in both groups. Conclusions Interpretation of the results is hampered by unevenly distributed baseline characteristics and more patients need to be investigated. In this small sample no beneicial efect of n-3 fatty acids on cerebral markers was found. Reference 1. Pister D, et al.: Cerebral perfusion in sepsis-associated delirium. Crit Care 2008, 12:R63. P562 Efects of an olive oil-based lipid emulsion (ClinOleic) versus LCT/ MCT-based lipid emulsions upon the inlammatory markers of critically ill patients (EPICOS Study) S Lima1, A Pontes-Arruda1, L Martins1, M Pinheiro2 1 Hospital Fernandes Tavora, Fortaleza, Brazil; 2Laboratório Evandro Pessoa, Fortaleza, Brazil Critical Care 2010, 14(Suppl 1):P562 (doi: 10.1186/cc8794) Introduction Olive oil-based lipid emulsions have been used for more than a decade to reduce the polyunsaturated fatty acid (PUFA) content in TPN, thus preventing the deleterious efects associated with PUFA excess. MCT/LCT-based lipid emulsions were recently associated with deleterious efects such as lipotoxicity, activation of inlammatory cascade and increased risk of cardiovascular disease [1]. This study aims to compare the efects of these two lipid emulsions upon several inlammatory markers in critically ill patients using TPN. Methods Serum samples were collected in a prospective multicenter and open-label study (NCT#00798681) from 100 critical care patients receiving TPN with an olive oil-based lipid emulsion using either a premixed readyto-use system (G1, n = 50, OliClinomel; Baxter) or a compounded system (G2, n = 25, ClinOleic; Baxter), and the results were compared with those from patients receiving a compounded TPN made with an LCT/MCT lipid emulsion (G3, n = 25). All samples were collected at baseline, day S188 4 and day 7 (three samples in each time point). Changes in the levels of inlammatory markers from baseline to day 7 were compared using analysis of covariance and P <0.05 was considered statistically signiicant. Results At baseline, demographic characteristics of the patients were balanced between the groups. Regardless of the delivery system used, patients receiving TPN with an olive oil-based lipid emulsion presented at day 4 lower levels of: IL-8 (54.4 vs 67.8 vs 120.7 pg/ml), TNFα (3.4 vs 3.5 vs 13.0 pg/ml), lymphocyte phosphatidylserine externalization (PS) (5.2 vs 4.8 vs 14.7%), and resistin (R) (9.1 vs 9.2 vs 15.4 ng/ml) (all G1 vs G2 vs G3 and P <0.05). No diferences were observed in the levels of IL-10 and CRP. Statistically signiicant diferences were maintained throughout day 7 for IL-8, TNFα, PS and R. Conclusions The administration of an olive oil-based lipid emulsion within the TPN regimen led to a signiicant reduction in the inlammatory response when compared with a LCT/MCT-based lipid emulsion. Particularly relevant are the diferences for resistin (an indicator of insulin resistance) and PS (an indicator of apoptosis). Reference 1. Pontes-Arruda: Clin Nutr Suppl 2009, 4:19. P563 Abstract withdrawn Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P564 Abstract withdrawn S189 A: postsurgical adult patients, 5 days total parenteral nutrition, 100 SMOF vs 103 SO patients; B: adult patients receiving parenteral nutrition for 28 days, 22 SMOF vs 32 SO patients. Patients with data at baseline and study end were selected. The data were pooled and diferences of laboratory data at 1 week minus baseline and study end minus baseline were calculated. Analyses of variance were applied using diferences between 1 week/study end values and baseline values of bilirubin (BIL), AST and ALT as dependent variables and treatment group as independent variable. Covariates used: baseline values for BIL, AST, ALT and mean daily dose of fat per kg body weight. Results Baseline values were not signiicantly diferent between the two treatment groups. The mean daily intake of fat/kg bw after 1 week and study end was the same between both treatment groups. One-week – baseline values of liver parameters (mean; SMOF group: BIL –5.1* μmol/l, AST –5.4** U/l, ALT 0.6*** U/l; SO group: BIL –2.0* μmol/l, AST 0.6** U/l, ALT 11.1*** U/l) were signiicantly diferent between treatment groups (P: 0.035*, 0.001**, 0.001***). Extending the analysis until 28 days did not alter the results. Conclusions Infusion of SMOFlipid 20% compared with a soybean oil standard lipid emulsion exerts a signiicant decrease in the values of BIL and AST. It also signiicantly attenuates the rise seen in ALT. These results indicate that SMOFlipid 20% is promising in preventing parenteral nutrition-induced liver disturbances. P566 Therapy of compartmentalization of the proinlammatory and anti-inlammatory cytokines in sepsis EG Grigoryev Kemerovo State Medical Academy, Kemerovo, Russia Federation Critical Care 2010, 14(Suppl 1):P566 (doi: 10.1186/cc8798) P565 Does a ish-oil-containing lipid emulsion improve liver function in comparison with a soybean oil lipid emulsion? J Linke1, H Topp1, I Mueller1, S Bark2, N Mertes3, H Grimm4, P Singer5, J Shafer6 1 Fresenius Kabi Deutschland GmbH, Oberursel, Germany; 2Visby Hospital, Visby, Sweden; 3Raphaelsklinik, Münster, Germany; 4Clinical Centre of Passau, Germany; 5General Intensive Care Department and Institute for Nutrition Research, Rabin MC, Petah Tikva, Israel; 6Salford Royal NHS Foundation Trust, Salford, UK Critical Care 2010, 14(Suppl 1):P565 (doi: 10.1186/cc8797) Introduction Liver function disturbances have been of concern in parenteral nutrition. The aim of the post hoc analyses of two pooled studies was to compare liver function parameters using ish-oil-containing vs soybean oil lipid emulsions. Methods Two prospective, controlled, randomized, parallel-group, double-blind, multicenter studies compared SMOFlipid 20%, a ishoil-containing lipid emulsion (SMOF: soybean oil 60 g, medium-chain triglycerides 60 g, olive oil 50 g, ish oil 30 g per l), vs standard soybean oil emulsion (SO, 200 g soybean oil/l). The studies were as follows: Introduction We supposed the diagnostic signiicance of the ratio between proinlammatory and anti-inlammatory cytokines in the peritoneal cavity and system blood low in patients with abdominal sepsis. So we tried to correct such disbalance with glutamine intravenous and enteral supplementation. Methods Prospective controlled randomized investigation of the patients with abdominal sepsis (excluding pancreatitis). Group 1 (n = 16): standard therapy. Group 2 (n = 11): with intravenous infusion of glutamine (Dipeptiven; Fresenius Kabi, Germany). Group 3 (n = 11): with intravenous infusion of glutamine and enteral supplementation of glutamine (Intestamine; Fresenius Kabi). The patients in groups were identical according to the severity of disease (APACHE II), the standard of intensive care, the volume of surgery care. We investigated the proinlammatory cytokines: TNFα, IL-1, IL-6, IL-8; and anti-inlammatory cytokines: soluble sTNF-RI and sTNF-RII, antagonist receptor IL-1, IL-10 in blood serum and in the peritoneal cavity during the initial 3 days of intensive care (ELISA; BD Biosciences Pharmingen, San Diego, CA, USA; EASIAs; Biosource, Nivelles, Belgium). Results The probability of survival on day 28 was 73% in the standard therapy group, in the group with glutamine intravenous – 78%, in the group with glutamine intravenous and enteral – 84%. We did not ix the decrease of the duration of respiratory support in all of the groups. The duration of acute intestinal injury was signiicantly diferent (standard group 49 hours vs 38 hours in group with glutamine intravenous supplementation – 35 hours in group with intravenous and enteral glutamine supplementation). We investigated the prevalence of the concentration of proinlammatory cytokines in the peritoneal cavity and in blood serum according to the molar coeicient in the control group. The molar coeicient had a positive correlation with the SOFA scale. In group 2 (glutamine intravenous) the molar coeicients were decreased to the prevalence of anti-inlammatory cytokines (in serum on day 3, in peritoneal on day 2). In group 3 (glutamine intravenous and enteral) we investigated the signiicance diference and decrease of all cytokine levels in blood serum and in the peritoneal cavity. Conclusions Intravenous and enteral supplementation of glutamine improved the cytokine balance in blood and the peritoneal compartment. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P567 Intensive insulin therapy and brief hypoglycemia do not increase neurological injury markers in critically ill children M Gielen, I Vanhorebeek, M Boussemaere, PJ Wouters, D Mesotten, G Van den Berghe Katholieke Universiteit Leuven, Belgium Critical Care 2010, 14(Suppl 1):P567 (doi: 10.1186/cc8799) Introduction Targeting glycemia to age-adjusted normal fasting blood glucose levels with intensive insulin therapy (IIT) improved short-term outcome of critically ill children as compared with conventional insulin therapy (CIT), but concomitantly increased the incidence of hypoglycemia [1]. Both hyperglycemia and hypoglycemia may adversely afect the developing brain of young children. We therefore studied the impact of targeting normoglycemia with IIT on circulating markers of brain injury in these patients. Methods This was a pre-planned analysis of all 700 pediatric critically ill patients included in a prospective, randomized, controlled study on IIT [1]. Patients were randomly assigned to the target of normal for age fasting blood glucose levels (2.8 to 4.4 mmol/l for age <1 year and 3.9 to 5.6 mmol/l for age ≥1 year) with insulin infusion throughout the ICU stay (IIT), or to insulin infusion only to prevent excessive hyperglycemia (CIT). Serum S100B and neuron-speciic enolase (NSE), markers of astrocytic and neuronal damage, were measured by ELISA on ixed days (n = 700) and before and after hypoglycemia in a nested case–control design (n = 126). Results Patients admitted to the ICU after cardiac surgery had higher admission S100B and NSE levels than patients in the other diagnostic categories (P <0.0001), with the highest levels observed for patients with the highest Risk Adjustment for Congenital Heart Surgery (RACHS) score (both P = 0.002). Admission levels of S100B and NSE were higher in patients needing intensive care for at least 3 days vs short-stay patients (both P <0.0001) and in ICU nonsurvivors vs survivors (P = 0.002 and P = 0.0002). IIT did not afect the levels of S100B or NSE as compared with CIT. Patients experiencing hypoglycemia at any time during the ICU stay revealed higher S100B and NSE levels on admission (P <0.0001 and P = 0.0007) than those without hypoglycemia. In the nested case–control study, S100B and NSE decreased after hypoglycemia (P = 0.001 and P = 0.009) in the cases, unlike in the controls on matched days. Conclusions IIT in the pediatric ICU did not evoke neurological damage, as evaluated by S100B and NSE, despite an increased incidence of brief hypoglycemia. Elevated markers in patients with hypoglycemia were not caused by hypoglycemia but explained by an increased risk of hypoglycemia in the most severely ill. References 1. Vlasselaers D, et al.: Lancet 2009, 373:547-556. P568 A cluster-controlled implementation project of intensive insulin therapy: efects on blood glucose control and incidence of severe hypoglycemia R Harmsen1, F Van Braam Houckgeest2, J Van der Sluijs3, H Van den Oever4, L Hofstra5, M Kuiper6, A Abu-Hanna1, P Spronk7, M Schultz1 1 Academic Medical Center, Amsterdam, the Netherlands; 2Tergooi Hospitals, Hilversum, the Netherlands; 3MCH, The Hague, the Netherlands; 4Deventer Hospital, Deventer, the Netherlands; 5Scheper Hospital, Emmen, the Netherlands; 6MCL, Leeuwarden, the Netherlands; 7Gelre Hospitals, Apeldoorn, the Netherlands Critical Care 2010, 14(Suppl 1):P568 (doi: 10.1186/cc8800) Introduction Intensive insulin therapy (IIT) is a complex intervention involving several steps that may all contain potential sources of variability. Changing practice in complex multidisciplinary environments is diicult. In addition, it is undecided whether IIT should be applied by nurses and physicians, or nurses alone. We implemented IIT using a conceptual implementation framework and compared overall blood glucose control and incidence of severe hypoglycemia (SH) (blood glucose level (BGL) <40 mg/dl) before and after implementation. S190 Methods Three ICUs developed and implemented an evidence-based guideline for IIT; three ICUs with no change in blood glucose control served as control ICUs. In the guideline ICUs, the IIT practice change comprised two periods: in the irst year after implementation of the guideline, physicians and nurses used the guideline together; in the second year the guideline was applied solely by nurses. BGL collection and analysis included the 1 year before implementation of the guideline. Analysis was performed using statistical process control. Results IIT guideline: the new guideline emphasized fast correction of high BGLs, acceptance of low BGLs and frequent BGL measurements (up to one/hour). Blood glucose control: BGLs of approximately 8,000 patients were collected and analyzed. The case mix was similar in guideline and control ICUs, and did not change over time. No change in overall blood glucose control or incidence of SH was observed in the control ICUs during the study duration. In the guideline ICUs, the median number of daily blood glucose measurements increased from 4 (3 to 7) per patient to 9 (5 to 12) per patient (P <0.001). Median morning BGL declined in guideline ICUs, from 114 (96 to 139) mg/dl to 100 (85 to 123) mg/dl (P <0.001). The change in blood glucose control was accompanied by a rise in the incidence of SH, from 7% to 13% (P <0.001). SH, however, did never cause short-term harm (no death or coma). Nurses alone performed equally well with regard to overall blood glucose control, and even showed a decline of incidence of SH. Conclusions Implementation of an evidence-based IIT guideline improves blood glucose control, with results comparable with the original studies on IIT in Leuven. The increase of incidence of SH is temporary, and improves when IIT is applied by nurses alone. P569 Incidence of hypoglycemia in NICE sugar not so nice after consideration of the treatment period JK Mader, G Bock, J Plank, G Köhler, TR Pieber, M Ellmerer Medical University Graz, Austria Critical Care 2010, 14(Suppl 1):P569 (doi: 10.1186/cc8801) Introduction Hypoglycaemia is one of the major side efects when establishing glycaemic control in critically ill patients and may contribute to increased mortality rates. Until today, no comparable measure of hypoglycaemia frequency has been suggested. Current assessments depend either on the treatment period or the number of glucose measurements performed per patient. Therefore, we suggest an alternative method to present the hypoglycaemia incidence by number of episodes per patient normalized for a 24-hour treatment period. Methods Two major studies performing glycaemic control in critically ill patients were chosen for comparison: the Leuven study with 1,200 patients at a medical ICU (605 standard care (STD), 595 tight glycaemic control (TGC); [1]) and the NICE study with 6,030 patients in a mixed ICU population (3,014 STD, 3,016 TGC; [2]). For both studies, rates of hypoglycaemia per patient per 24 hours were calculated based on published data. Results Mean duration of treatment was 12.5 days for the Leuven study and 4.2 days for the NICE study. APACHE scores were 23 for Leuven and 21 for NICE, respectively. Number of hypoglycaemic events per study population was reported as follows: 19 (3.1%) for STD and 111 (18.7%) for TGC for the Leuven study and 15 (0.5%) for STD and 206 (6.8%) for TGC in the NICE study. When applying the new evaluation method, rates of hypoglycaemia per patient per 24 hours were 0.25% (STD) vs 1.49% (TGC) for Leuven and 0.12% (STD) vs 1.63% (TGC) for NICE, respectively. Conclusions The results reveal that the treatment period may have a signiicant impact on the reported rate of hypoglycemia. We conclude that reporting hypoglycaemic episodes in critically ill patients on a perpatient and per-24-hour basis may be a more adequate tool to accurately describe hypoglycaemia incidence which facilitates the comparison between diferent studies and study protocols. References 1. 2. Van den Berghe et al.: N Engl J Med 2006, 354:449-461. NICE-SUGAR Study Investigators: N Engl J Med 2009, 360:1283-1297. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P570 Comparison of a planned versus emergent approach implementation of tight glycemic control therapy on an ICU: an experimental design M Luiking1, L Bras1, R Van Linge2, M Grypdonck2 1 St Antonius Ziekenhuis, Nieuwegein, the Netherlands; 2Universiteit Utrecht, the Netherlands Critical Care 2010, 14(Suppl 1):P570 (doi: 10.1186/cc8802) Introduction In this study the efectiveness of a hierarchic planned approach to implementation was compared with an emergent approach with a high degree of nurse participation. The innovation was a new tight glycemic control (TGC) therapy in the ICU. The implementation method to introduce a new evidence-based treatment to the ICU can make a diference to its efectiveness. New treatment procedures are very often strictly deined and introduced on the ICU in a top-down manner. On theoretical grounds, a bottom-up implementation method, with more participation and involvement of the ICU nurses, should be more efective. Methods In an experiment a TGC protocol was introduced on a 24-bed ICU with 120 ICU nurses. In one nursing team the implementation was by means of the usual planned approach (PA). In the other team an emergent implementation approach (EA) was applied. During 7 months, 1,182 patients were admitted and randomly assigned to either team. The efectiveness of the implementation methods was measured at patientoutcome (glucose) level and on a process-execution (nurse compliance) level. The patient-outcome measurements were: mean glucose value, percentage of normal glucose values (deined as between 4.0 and 6.5 mmol/l) and the time from admission to reach a normal glucose level (6.5 mmol/l). For the mean glucose value a diference was made between short-stay (<3 days) and long-stay patients (≥3 days). The compliance was expressed as compliance for safe, insulin treatment (the patient received the right amount of insulin) and compliance for eicient treatment (glucose measurements as well as insulin were according to the protocol). Results The mean glucose for the short-stay patients was signiicantly lower in the EA than the PA team (6.42 vs 6.52 mmol/l), no signiicant diference was found for the long-stay patients. The percentage of normal glucose values was 53.9% in the EA and 52.8% in the PA team (signiicant P <0.001). The time to reach normal glucose levels was 6 to 7 hours in the EA and 10 to 11 hours in the PA team (signiicant, P <0.05). The compliance for safe insulin treatment was 91.3% in the EA and 79.0% in the PA team. The compliance for eicient treatment was 83.5% in the EA and 66.8% in the PA team. Conclusions An emergent approach to implementation (with an increased participation of the ICU nurses) of a TGC resulted in better patient results and a higher compliance to the protocol. P571 Coagulation proile in hyperglycemic septic shock patients LC Sanches, D Lourenco, R Salomao, MA Noguti, M Brunialti, C Steula, M Assuncao, F Machado Federal University of São Paulo, Brazil Critical Care 2010, 14(Suppl 1):P571 (doi: 10.1186/cc8803) Introduction A hypercoagulable state is frequently found in sepsis patients as well as hyperglycemia [1]. The objective of this study was to determine the coagulation proile in hyperglycemic septic shock patients and the impact of glycemia control. Methods Septic shock patients with less than 48 hours of organ dysfunction with normoglycemia (<150 mg/dl, Group 1) or hyperglycemia (>200 mg/dl, Group 2) were included. Exclusion criteria were previous diabetes, coagulation diseases, use of heparin or fresh frozen plasma/ platelets, sepsis in the past 30 days or insulin use in the past 24 hours. The coagulation and inlammation proile was determined at inclusion and after 24 hours, only if the patients remained normoglycemic or achieved glycemic control with insulin infusion (Group 2). Results were expressed in median and interquartiles, P <0.05 was considered signiicant. Results Forty-one patients were included, 59.7% male; mean APACHE II score: 16.9 ± 8.6, P = 0.21; mean SOFA score: 8.1 ± 2.0; mean number of S191 organ dysfunctions: 3.6 ± 0.9, with a signiicant diference between the groups only regarding age (Group 1 (n = 21): 53.8 ± 16.7, Group 2 (n = 20): 68.8 ± 16.4, P = 0.006). In both groups, a hypercoagulation proile was detected, with high levels of fragment 1+2 (F1+2), thrombin/antithrombin complex (TAT), D-dimer and tissue factor and with low levels of factor VII. Consumption of coagulation inhibitors (protein C (PC), antithrombin (AT), tissue factor pathway inhibitor) and increased ibrinolysis (plasminogen activator inhibitor 1 (PAI-1), tissue plasminogen activator (TPA) and plasminogen) were also found. However, at baseline no signiicant diference between groups was found except for a trend towards high levels of F1+2 (P = 0.08) and TAT (P = 0.058) in Group 2. After 24 hours higher levels of AT (P = 0.02), PC (P = 0.02), plasminogen (P = 0.04) and a reduction in PAI-1 (P = 0.01) and TPA (P = 0.03) were detected in Group 2. Inlammatory parameters (IL-6, IL-8, IL-10, TNF) were similar at baseline, with decreased levels in both groups after 24 hours but the IL-6 (P = 0.02) and IL-8 (P = 0.0004) reduction was more pronounced in Group 2. Conclusions Septic shock patients have a hypercoagulation pattern regardless of their glycemic status. However, glycemia control seems to be associated with reduction in inlammation and hypercoagulation parameters, possibly related to insulin infusion as glycemia levels did not difer between groups after 24 hours. Acknowledgements Financial support from FAPESP. Reference 1. Machado FR, et al.: Endocr Metab Immune Disord 2006, 26:175-182. P572 Impact of glycemic control on survival in critical care patients with sepsis R Tiruvoipati, D Lewis, K Ong, M Gupta, K Haji, J Botha Frankston Hospital, Frankston, Victoria, Australia Critical Care 2010, 14(Suppl 1):P572 (doi: 10.1186/cc8804) Introduction Several studies have shown an increased mortality and morbidity in various groups of patients with hyperglycemia requiring admission to the ICU. Contrary to these studies, a recent large multicentric international trial in ICU patients has shown an increased mortality in patients where normoglycemia was maintained. However, very few studies speciically evaluated the association between hyperglycemia and mortality in critical care patients with sepsis. Since hyperglycemia is known to be associated with immunosuppression and increased risk of life-threatening infections, we aimed to assess the impact of glycemic control (normoglycemia) in ICU patients with sepsis. Methods We studied all patients admitted to our ICU with sepsis between July 2004 and May 2009. Patients were excluded if their blood sugar levels (BSL) were not measured at least once every 6 hours during their ICU stay. Patients were divided into two groups based on their glycemic control in the ICU: normoglycemic group (BSL 3.9 to 6.2 mmol/l) and conventional glucose control group (BSL 8 to 10 mmol/l). BSLs were controlled using an infusion of actrapid insulin. Both groups were compared with regard to demographics, co-morbidities, severity of illness at ICU admission (APACHE III and SAPS II scores), ICU and hospital mortality and length of stay. Results Over the 5-year study period a total of 314 patients were admitted with sepsis and 297 patients were included. On average every patient included in the study had BSL once every 4.2 hours throughout their ICU stay. Of these patients, 68 had normoglycemia (mean BSL 5.6) and 229 had conventional glucose control (mean BSL 8.5) during their ICU stay. There was no statistically signiicant diference between the groups in age, sex, APACHE III and SAPS II scores. The ICU mortality was signiicantly higher in the normoglycemic group (30.8% vs 14.8% P <0.01). There was no statistically signiicant diference in hospital mortality between both groups (33.8% vs 25.3% P = 0.16). The ICU (median and IQR days: 1 (1 to 3) vs 4 (2 to 7) P = <0.01) and hospital duration of stay (6.0 (2.00 to 13.75) 6.0 (2.00 to 13.75) vs 12.0 (7.00 to 27.00); P <0.01) were signiicantly higher in the conventional group. Conclusions The ICU mortality in patients admitted to the ICU with sepsis who had normoglycemia was higher than in those patients who had conventional glucose control during their ICU stay. Aiming for a normal blood glucose levels is not indicated in patients with sepsis while they are in the ICU. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S192 P573 Therapeutic impact on intravenous insulin dosing with three new point-of-care glucose meters in an adult ICU L Schmitz, M Suball, C Hanicq, T El-Mahi, V Piersoel, E Stevens, A Roman CHU Saint-Pierre, Brussels, Belgium Critical Care 2010, 14(Suppl 1):P573 (doi: 10.1186/cc8805) Introduction Glycemic control is mandatory in the critically ill, because hypoglycemia and hyperglycemia are associated with increased mortality [1]. We compared in a prospective observational study three new pointof-care devices with the hexokinase reference method and we evaluated whether their results would modify insulin titration. Methods Arterial blood glucose was simultaneously measured by the blood gas analyser RapidLab 1265, by three glucose meters (Accu-Chek performa, Precision XceedPro, Nova StatStrip), and with the hexokinase reference method. All values were duplicated and the average value of each was computed. Bland–Altman, Passing Bablok, Kanji [2] and modiied Kanji approaches were performed. Biases were expressed as the glucose result of the point-of-care method minus the reference method. We evaluated the theoretical impact on insulin titration by comparing glucose meter results with the hexokinase reference method on a dynamic sliding scale targeting a glycemia of 80 to 130 mg/dl. Results A total of 156 matched analyses were done in 80 patients. The mean lash SOFA score was 4.5. The range of the reference glucose was 25 to 327 mg/dl. The numbers of discrepancies of dosing insulin were respectively 8-5-6-14 at 0.1 U/hour, 0-6-3-6 at 0.2 U/hour and 2-3-0-0 at 0.3 U/hour. None was greater than 0.3 U/hour. Regarding the point-of-care results, total theoretical insulin dose changes were respectively: –11.7 U, –19.2 U, –22.2 U, +4.9 U for all these measurements (devices order as in Methods). Table 1 presents the standard comparisons. (4) relationships among BG parameters, and (5) probable factors afecting BG variability (BGsd) including demographic data, SOFA score and MOF score (calculated using the criteria proposed by the Japanese Association for Critical Care Medicine, 1990). Results (1) Mortality of the patients with BGsd below 14 mg/dl (group BGsd14b, n = 41) was signiicantly lower than that with BGsd above 14 mg/dl (group BGsd14a, n = 26) (17% vs 46%, P <0.025). (2) AS (%) was as follows: BGm <196 mg/dl (75%), BGsd <17 mg/dl (73%), BGmax <225 mg/dl (72%), BGmin <172 mg/dl (72%), and BGd <8 0 mg/dl (70%). (3) Signiicant (P <0.002) positive correlation was found between BGsd and BGd (r = 0.87), BGsd and BGmax (r = 0.79), and BGd and BGmax (r = 0.77). (4) There was a tendency that the ratio of the patients with MOF score above 3 was lower in group BGsd14b than that in group BGsd14a (7% vs 23%, P <0.10), although there was no signiicant diference between the groups in BGm, demographic data, and SOFA score. Conclusions First, high BG variability in the early phase, which appeared to accompany severe illness and could be evaluated by BGsd, BGd, and BGmax, was considered to be one of the signiicant risk factors as well as high BG or elevated BGm. Stabilizing BG variability from the early phase was suggested to be important for mortality reduction. Second, AP was reliable for elucidating the signiicance of strict BG control, and was considered to be a valuable therapeutic artiicial organ for the better outcome of the ICU patients through the strict BG control. P575 Blood glucose amplitude variation: efects of intensive insulin therapy and relative association with mortality E Bekaert, P Wouters, A Wilmer, G Van den Berghe, G Meyfroidt UZ Leuven, Belgium Critical Care 2010, 14(Suppl 1):P575 (doi: 10.1186/cc8807) Table 1 (abstract P573) Bias and 2SD Passing reg CI of slope RapidLab –4.7 ± 14.6 Y = –4.8 + 1.1X 1.04 to 1.10 AccuChek P –9.5 ± 20.5 Y = 3.6 + 1.05X 1.00 to 1.11 P Xceed Pro –0.9 ± 15.4 Y = –4 + 1.03X 1.00 to 1.08 Statstrip No 1.2 ± 18.1 Y = –0.4 + 0.98X 0.93 to 1.03 Conclusions Glucose monitoring with new glucose meters results has minor impact on intravenous insulin dose titration compared with the reference method. References 1. 2. Van den Berghe G: J Clin Endocrinol Metab 2009, 94:3163. Kanji S: Crit Care Med 2005, 33:2778. P574 Signiicance of blood glucose variability in the early phase for predicting survival in acutely ill patients with glucose intolerance M Hoshino1, Y Haraguchi2, I Mizushima3, M Sakai4, S Kajiwara1, M Takagi1 1 Shisei Hospital, Saitama, Japan; 2National Hospital Organization Disaster Medical Center, Tokyo, Japan; 3Nippon Engineering College, Tokyo, Japan; 4 Tokyo Women’s Medical University Hospital, Tokyo, Japan Critical Care 2010, 14(Suppl 1):P574 (doi: 10.1186/cc8806) Introduction Although high blood glucose (BG) causes high mortality in ICU patients, signiicance of BG variability is not elucidated. The purpose of the study was to clarify the signiicance of BG variability in the early phase for predicting survival and to suggest the importance of stabilizing BG variability for mortality reduction. Methods Strict BG control was performed by bedside-type artiicial pancreas (AP), STG22. The number of the selected patients was 67, or patients with daily mean BG (BGm) below 200 mg/dl in early phase (3.2 ± 2.5 days after admission). Studied items: (1) mortality, (2) BG parameters (mg/dl): BGm, daily standard deviation of BG (BGsd), daily maximal and minimal BG (BGmax, BGmin), and daily BG diference (BGd:BGmax – BGmin), (3) accuracy (%) of the BG parameters for predicting survival (AS), Introduction There is growing evidence that not only blood glucose (BG) level but also BG amplitude variation (BGAV) is associated with mortality in critically ill patients [1]. Methods Retrospective analysis of the data of the Leuven intensive insulin therapy (IIT) trial in 1,200 MICU patients, randomized to receive either IIT or conventional insulin therapy [2]. The hyperglycemic index (HGI) and hypoglycemic index (HoGI) were used as measures of BG level, the standard deviation of all BG readings per patient (SD BG) as a measure of BGAV. The univariable efect of IIT on these indices was analyzed, the independent association with hospital mortality was assessed by multivariable logistic regression (MVR), corrected for baseline risks. Results IIT reduced the median HGI from 3.2 to 0.8 mmol/l (P <0.0001), increased the median HoGI from 0.005 to 0.048 mmol/l (P <0.0001), and did not afect median SD BG (conventional: 2.12; IIT: 1.99 mmol/l (P = 0.161)). The results of the MVR are summarized in Table 1. HGI, HoGI and SD BG were independently associated with mortality. Conclusions BGAV was associated with mortality in MICU patients, independent of baseline risks and BG level. IIT reduced HGI, increased HoGI, and did not afect BGAV. Reducing BGAV, in addition to IIT, may theoretically increase its potential for clinical beneit. References 1. 2. Krinsley et al.: Crit Care Med 2008, 36:3008-3013. Van den Berghe et al.: N Engl J Med 2006, 354:449-461. Table 1 (abstract P575) Risk P value Malign <0.001 Female 0.309 BMI >25 0.044 Age 0.001 Adm BG 0.002 HGI <0.001 HoGI 0.003 SD BG 0.024 Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S193 P576 Prevention of fatal and disabling neuroglycopaenia: a comparison of arterial blood sampling methods KA Brennan, D Turnbull Sheield Teaching Hospitals NHS Trust, Sheield, UK Critical Care 2010, 14(Suppl 1):P576 (doi: 10.1186/cc8808) P577 Impact of real-time continuous glucose monitoring on glucose variability in critically ill patients R Brunner, R Kitzberger, W Miehsler, V Fuhrmann, C Madl, U Holzinger Medical University of Vienna, Austria Critical Care 2010, 14(Suppl 1):P57 (doi: 10.1186/cc8809) Introduction In 2008, the UK National Patient Safety Agency (NPSA) published a report following 42 incidents and two deaths where glucosecontaining lush solutions were attached to arterial lines. Deaths occurred when blood samples contaminated with the lush solution led to artiicially high blood glucose readings, inappropriate insulin administration and iatrogenic neuroglycopaenia (the molar concentration of 5% glucose at 277 mmol/l is huge next to physiological blood glucose at <11 mmol/l). The NPSA sought a solution so we applied a bench model to test the performance of three open and three closed arterial line systems in preventing sample contamination. Methods All arterial line systems were set up in a standard manner and pressurised to 300 mmHg with 5% glucose used as the lush solution. This was connected to the radial artery using an 18 G needle representing the radial cannula. The radial artery was simulated using a wide bore extension set with blood low at 60 ml/minute. Blood was simulated by the addition of red dye to Hartmann’s solution. Increasing multiples of arterial line dead space were aspirated and discarded. Blood samples were then taken and the glucose concentration measured. Results Signiicant glucose contamination (3 mmol/l ± 3.4) was detected in all open arterial line systems up to an aspiration volume of ive times the dead space. No samples from the closed systems recorded glucose concentration >1 mmol/l (0.2 ± <0.1) (Figure 1). Conclusions Recommended minimal discard volumes are inadequate in the presence of glucose as the lush solution. Human factors ensure that such errors can persist without a systems-based solution. Our study demonstrates that the closed loop arterial sampling system could be the universal solution sought by the NPSA. Introduction Glucose variability has been found to be associated with mortality in critically ill patients, independent of the mean glucose concentration [1]. The aim of this analysis was to assess the impact of real-time continuous glucose monitoring (CGM) on glucose variability in critically ill patients receiving intensive insulin therapy (IIT). Methods This is the post hoc analysis of a prospective, randomized, controlled trial [2]. Data of 124 patients admitted to the ICU either receiving IIT according to a real-time CGM system (Guardian®; Medtronic, Northridge, CA, USA) (n = 63) or according to an algorithm (n = 61) with selective arterial blood glucose measurements (simultaneously blinded CGM) for 72 hours were analysed. Insulin infusion rates were guided according to the same algorithm in both groups. Mean glucose and standard deviation, as a marker of glucose variability, were calculated for the irst 24 hours (GluMEAN1, GluSD1) and for the whole study period (GluSD). Statistical comparison of parameters between study groups and between ICU survivors (n = 94) and nonsurvivors (n = 30) was performed using Student’s t test. Results The variability of sensor glucose during the entire study period was comparable between the real-time CGM group and controls (21.51 ± 1.10 vs 23.44 ± 1.26 mg/dl; P = 0.243). Although the mean sensor glucose during the irst 24 hours in the ICU showed a trend towards lower values in the intervention group (real-time CGM vs control: GluMEAN1: 104.40 ± 2.00 vs 109.23 ± 1.96 mg/dl; P = 0.087), variability of sensor glucose during the irst 24 hours did not difer signiicantly (real-time CGM vs control: GluSD1: 20.85 vs 18.46 mg/dl; P = 0.201). GluSD tended to be lower in ICU survivors (ICU survivors vs nonsurvivors: 21.61 ± 8.60 vs 25.10 ± 10.55 mg/dl; P = 0.071) whereas GluSD1 (19.06 ± 9.32 vs 21.41 ± 13.21 mg/dl; P = 0.282) Figure 1 (abstract P576). Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 and GluMEAN1 (106.39 ± 14.83 vs 108.00 ± 18.44 mg/dl; P = 0.627) were not diferent between ICU survivors and nonsurvivors. Conclusions IIT guided by real-time CGM did not result in reduced glucose variability compared with IIT according to an algorithm with selective arterial blood glucose measurements. Although mean sensor glucose during the irst 24 hours tended to be lower in the real-time CGM group, glucose variability was not diferent between the two groups. GluSD tended to be lower in ICU survivors irrespective of glucose monitoring. References 1. 2. Egi M, et al.: Crit Care 2009, 13:302. Holzinger U, et al.: Diab Care 2009, in press. P578 Automated blood glucose monitor is insensitive to hematocrit variation and common saccharide interferents S Hendee, S Vanslyke, J Faught, A Truong, W Patterson, R Thompson Luminous Medical, Carlsbad, CA, USA Critical Care 2010, 14(Suppl 1):P578 (doi: 10.1186/cc8810) Introduction Luminous Medical is developing an automated, patientattached system (Argus Glucose Monitoring System) that uses a lowthrough glucose oxidase sensor to measure plasma glucose levels in whole blood. The Argus GMS will aid caregivers in achieving glycemic control in critical care patients. The FDA has recently indicated that ICU glucose monitors need to satisfy tighter accuracy requirements than those speciied by ISO 15197 (±15 mg/dl or ±20%). Luminous conducted a study to demonstrate Argus GMS accuracy under conditions of variable hematocrit, and in the presence of common saccharide interferents. Methods Hematocrit Study Group: one unit of whole blood was collected under an IRB-approved protocol from two healthy volunteers. Blood samples were prepared at three hematocrit levels (~24, 36, and 48%). Three glucose levels were tested at each hematocrit: native glucose, native plus 100, and native plus 200 mg/dl. Repeats were measured for each hematocrit/glucose combination (n = 99 total samples in this study group). Interferent Study Group: blood samples were prepared at native hematocrit (~37%) and native glucose level (~100 mg/dl). Testing followed established interference testing guidelines [1]. Blood samples were spiked with concentrated interferent solution or with equal volume of normal saline. Testing alternated between interferent-containing and interferentfree samples (n = 5 test and ive control samples for each interferent). Saccharide interferents included maltose (55 mg/dl), galactose (15 mg/dl), fructose (18 mg/dl), and xylose (40 mg/dl). In both study groups, blood samples were measured in vitro, in real time, using the Argus GMS in multisample mode. Plasma measurements from two YSI 2700 instruments were averaged to provide reference glucose values. Figure 1 (abstract P579). Clarke Error Grid for (a) OR/ICU and (b) in-clinic. S194 Results Hematocrit Study Group: the Argus GMS measured plasma glucose across a range of 50 to 350 mg/dl with RMS error of 5.5 mg/dl (mean error 2.6, 95% CI = –7.0 to 12.2, R = 0.998). The Argus GMS showed no sensitivity to hematocrit variation. Interferent Study Group: the Argus GMS showed minimal glucose measurement bias for each of the four saccharide interferents (maltose 2.21 mg/dl, galactose 4.09 mg/dl, fructose 2.63 mg/dl, and xylose 2.03 mg/dl). Conclusions The Argus GMS provides highly accurate glucose readings in whole blood samples with no observable sensitivity to hematocrit variation and with minimal inluence from saccharide interferences. Argus demonstrated measurement accuracy within ±10 mg/dl or ±10% at 95% conidence limits. Reference 1. Clinical and Laboratory Standards Institute: Interference Testing in Clinical Chemistry: Approved Guideline – Second Edition. Wayne, PA: Clinical and Laboratory Standards Institute; 2005. P579 Performance of an automated blood glucose monitor in the OR/ICU M Higgins1, G Bochicchio2, P Simpson3, J Leach3, A Kamath3, D Deyette1 1 Edwards Lifesciences, LLC, Irvine, CA, USA; 2University of Maryland School of Medicine, Baltimore, MD, USA; 3Dexcom, Inc., San Diego, CA, USA Critical Care 2010, 14(Suppl 1):P579 (doi: 10.1186/cc8811) Introduction DexCom and Edwards Lifesciences collaborated to develop an intravenous blood glucose monitor for use in a critical care environment. The system provides automatic, real-time monitoring and trending of blood glucose (BG) values for critical care patients. The system is designed to address the needs of clinicians to monitor BG in critical care units. The sensor was also designed to accurately measure BG even in the presence of many drugs commonly used in the hospital. Methods This was a blinded, multicenter study evaluating 17 adult patients presenting to the OR and ICU. They were monitored for up to 72 hours with reference samples taken at 4-hour intervals and measured with a YSI-2300 laboratory analyzer. Data are from initial roll-in patients used for training and assessing protocol complications. Reference blood samples were taken from either a peripheral vein, a central venous catheter or an arterial line. Glucose values were calculated prospectively but not displayed during the study. Results Of 211 paired BG measurements, 94.3% were within Clarke Error Grid A, 5.7% in B and 0% in C, D and E (Figure 1a). The mean absolute relative diference was 6.5%. No signiicant errors due to drugs were measured. These results compare favorably with a previous study of 50 subjects who were monitored continuously for up to 72 hours in a diabetic Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S195 in-clinic study (Figure 1b) where large excursions of BG could safely be evaluated. Conclusions The results of this study help illustrate the capability of the system to provide safe, accurate, automated glucose measurements in critical care patients. P581 Validation of HbA1c as a diagnostic marker for diabetes in the critically ill I Gornik, A Vujaklija-Brajković, V Gašparović University Hospital Centre Zagreb, Croatia Critical Care 2010, 14(Suppl 1):P581 (doi: 10.1186/cc8813) P580 ICU glucose monitoring measured in plasma using mid-infrared spectroscopy T Heise1, L Nosek1, J Gable2, G Lim2, C Calentine2 1 Proil Institut für Stofwechselforschung GmbH, Neuss, Germany; 2OptisScan Biomedical, Inc., Hayward, CA, USA Critical Care 2010, 14(Suppl 1):P580 (doi: 10.1186/cc8812) Introduction Diabetes mellitus (DM) is a highly prevalent disease: about one-quarter of patients admitted to hospital is diagnosed with DM, but there are also a large number of patients who are undiagnosed. An acutely ill patient with hyperglycaemia and no history of diabetes may have stress hyperglycaemia or a irst manifestation of diabetes, but it is virtually impossible to establish diagnosis based on measurements of glucose. HbA1c is widely used as a marker of glycaemic control and has been proposed and used, but not yet oicially accepted, as a diagnostic marker for diabetes. We have tested its usefulness for diagnosing diabetes in the intensive care setting. Methods We have included a cohort of adult patients admitted to a medical ICU. HbA1c was measured in all patients. Patients without hyperglycaemia during their illness and negative history of DM were used as negative controls; patients with known diagnosis of DM, impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) were positive controls. All patients with negative history for DM and hyperglycaemia in ICU were called for measurement of fasting glucose and OGTT within 1 month after discharge. Results There were 618 patients in the cohort: 138 with no hyperglycaemia, 79 with a history of IFG or IGT, 108 with a history of diabetes; 293 patients had hyperglycaemia during the ICU stay and no information about DM in the history. When analysing only positive and negative controls, a cut-of value of 6% showed 95% sensitivity and 93% speciicity for pre-diabetes (IFG and IGT), cut-of of 7% had 91% sensitivity and 96% speciicity for DM. Similar results were obtained for the group of patients with hyperglycaemia and no history of impaired glucose metabolism: cut-of of 6% had 97% sensitivity and 93% speciicity for pre-diabetes, 7% cut-of had 95% sensitivity and 98% speciicity for DM. Conclusions HbA1c can be used for diagnosing diabetes and prediabetes in patients with critical care hyperglycaemia with high sensitivity and speciicity. Since diabetes brings a burden of complications, impaired immune response, susceptibility to infections, and overall higher mortality, diferentiating diabetics from patients without diabetes can be very valuable. Introduction There are increasing calls for a highly accurate, automated system to enable tight glycemic control and avoid hypoglycemia in an ICU setting. OptiScan Biomedical has developed a glucose monitor based on mid-infrared spectroscopy that draws blood samples (120 μl) and measures plasma glucose concentrations approximately every 15 minutes. The goal of this study was to validate the performance of the OptiScan model 5000 (OptiScanner) at diferent glycemic levels in a healthy diabetic patient population. Methods Eighteen people (14 males, age 44 (18 to 64) years, BMI 29.0 (21.9 to 37.5) kg/m2) with type 1 (n = 8) or type 2 (n = 10) diabetes were connected to an OptiScanner. Their blood glucose concentrations were kept in a euglycemic (75 to 180 mg/dl), hypoglycemic (<75 mg/dl) and hyperglycemic (>180 mg/dl) range by intravenous administrations of insulin and glucose. Each OptiScanner blood sample was automatically withdrawn from a forearm vein. Blood samples for reference measurements using the YSI 2300 were withdrawn from the same arm within 60 seconds of the OptiScanner draw and analyzed immediately. A total of 250 paired data points in each glucose range will be collected in this ongoing study. Results The aggregate data points (374 paired readings between the OptiScanner and the YSI 2300) were within ISO standard, with 98.9% of the glucose values within ±20% above 75 mg/dl and ±15 mg/dl below this value. A Clark Error Grid analysis showed a total of 369 points (98.7%) in zone A (Figure 1). Points outside A exceeded the A zone boundary by an average of 5.3% and a maximum of 8.7%. The total coeicient for variance was 5.7%. The total r2 was 0.99. Conclusions These preliminary results show that the OptiScanner is highly accurate in a healthy diabetic population. P582 Efect of intravenous glucocorticoids on the eiciency of tight glycaemic control J Herbots1, G Mwani2, D Cottem1, D Mesotten3 1 UZ Leuven, Belgium; 2St-Jozef Ziekenhuis, Turnhout, Belgium; 3KU Leuven, Belgium Critical Care 2010, 14(Suppl 1):P582 (doi: 10.1186/cc8814) Figure 1 (abstract P580). Introduction Intravenous glucocorticoids (GC) are often administered during critical illness in the context of post-transplant immunosuppression, ARDS, septic shock or severe inlammatory vasoplegia. As a counterregulatory hormone of insulin, GC may interfere substantially with tight glycaemic control to normal for age blood glucose levels by intensive insulin therapy. Therefore we hypothesized that the irst administration of an intravenous GC gives rise to signiicant hyperglycaemia and that the efect is more pronounced for the synthetic GC. Methods All patients admitted to the surgical and paediatric ICU between 1 July 2008 and 1 July 2009 were screened for intravenous glucocorticoid use in our patient data management system. In those patients, arterial blood glucose levels, all measured by blood gas analyzer, within the time frame of 48 hours surrounding the GC administration were retrieved. Up to two baseline blood glucose levels (before GC administration) and up to six blood glucose levels post administration were analysed by repeatedmeasures ANOVA. Data are expressed as mean ± SD or as median (IQR). Results A total of 452 patients – n = 26 (<1 year), n = 76 (1 to 17 years), n = 350 (>17 years) – received intravenous GC: hydrocortisone 32%, bolus methylprednisolone 52%, drip methylprednisolone 4% and dexamethasone 12%. Baseline blood glucose levels were 97 ± 34 mg/dl (<1 year), 104 (89 to 132) mg/dl (1 to 17 years), 136 (106 to 174) mg/dl Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 (>17 years). In the adult patients the irst blood glucose measurement was 1.0 (0.4 to 2.0) hours after GC administration. Blood glucose levels decreased over time from baseline after GC administration (P <0.0001). The sixth glycaemia was 110 (91 to 139) mg/dl taken 12.4 (9.6 to 16.5) hours after GC administration. This decrease of glycaemia was only present in patients who received 92 ± 35 mg hydrocortisone (P = 0.004) or 40 (20 to 125) mg bolus methylprednisolone (P <0.0001). In patients who received 113 (71 to 160) mg drip methylprednisolone (P = 0.14) or 10 (5 to 12.5) mg dexamethasone (P = 0.44), blood glucose levels did not change over time. Conclusions We showed that, when a tight blood glucose protocol is implemented, intravenous GC administration does not necessarily lead to an increase in blood glucose level. The blood glucose proile after methylprednisolone or dexamethasone administration did not difer from the glycaemic response after hydrocortisone administration. However, avoiding hyperglycaemic peaks after the GC administration during tight glycaemic control requires an on average 2-hourly blood glucose measurement. P583 Chronic critical illness: high levels of estrogens and mortality G Bernardeschi, B Ferro, R Mori, A Abramo, F Forfori, F Giunta Scuola di Specializzazione di Anestesia e Rianimazione, Università degli Studi di Pisa, Italy Critical Care 2010, 14(Suppl 1):P583 (doi: 10.1186/cc8815) Introduction Chronic critical illness is characterized by a severe metabolic disorder, caused by the loss of the physiologic hypothalamic and pituitary functions and the onset of the so-called wasting syndrome, as many studies have just conirmed [1]. In this study we assessed the correlation between the neuroendocrine pattern in chronic ICU patients and mortality. Methods The patients enrolled were 25 (18 male and ive female) with a mean age of 67 years and APACHE II score of 12 ± 5. We excluded females in a premenopausal state, patients with previous endocrine problems or in therapy with dopamine, high dose of cortisone or amiodarone. In these patients, we evaluate, on the seventh day of stay in the ICU (considered the chronic phase of critical illness), the mean value of four nocturnal hormonal measurements (LH, FSH, estrogen, testosterone, DHEAS, androstenedione, androstenediol, progesterone, TSH, FT3, FT4, RT3, GH, IGF1, prolactin, cortisol). Furthermore, we observed hormonal patterns in people who died in the ICU. Results We found statistical evidence in the correlation of high levels of estrogens, related to aromatase increased function [2], and the percentage of death. In the group of patients with estrogens more than 50 pg/ml, six of them died, while if estrogens were normal or low, none died (Figure 1). Survivors and nonsurvivors did not difer by mechanism of injury or S196 APACHE score (11.6 vs 11.8). Medium serum estradiol levels were 44.96 pg/ ml in survivors and 115.08 pg/ml in nonsurvivors. Conclusions To date, the role of these hormones in critical illness pathophysiology and the increase of estrogen levels are still uncertain. Further studies are required. References 1. 2. Van den Berghe G: Frontiers Neuroendocrinol 2002, 23:370-391. Spratt DI, et al.: Am J Physiol Endocrinol Metab 2006, 291:E631-E638. P584 Estrogen decreases inlammation and apoptotic signaling in the heart following severe burn injury JW Gatson, Q Zang, DL Maass, JP Minei, AH Idris, PE Pepe, J Wigginton University of Texas Southwestern Medical Center at Dallas and the Parkland Health and Hospital System, Dallas, TX, USA Critical Care 2010, 14(Suppl 1):P584 (doi: 10.1186/cc8816) Introduction Patients with severe burn injury experience a rapid elevation in multiple circulating proinlammatory cytokines, with the levels correlating with both injury severity and outcome. Accumulations of these cytokines in animal models have been observed in remote organs, however data are lacking regarding early serial heart cytokine levels following burn injury, and the therapeutic efects of estrogen on these levels. Using an animal model, we studied the acute efects of a fullthickness third-degree burn on cardiac levels of IL-1β, IL-6, IL-10, and TNFα. In addition, we analyzed the efect of estrogen on levels of cytochrome C, signifying apoptosis, and levels of NF-κB, signifying inlammation. Here, we hypothesized that acute estrogen treatment decreases inlammation in the heart and blocks the induction of apoptosis. Methods In this study, 144 male rats received third-degree 40% total body surface area burns. Fifteen minutes following burn injury, the animals received a subcutaneous injection of either placebo or 17β-estradiol (0.5 mg/kg). The hearts were harvested at 0.5, 1, 2, 4, 6, 8, 12, 18, and 24 hours after injury, and the heart cytokine (IL-1β, IL-6, IL-10, TNFα) levels were measured using the ELISA method. In addition, we assessed the cytosolic levels of cytochrome C and NF-κB at the 24-hour time point using western blot analysis. Results In the burned rats, 17β-estradiol signiicantly decreased the cardiac levels of TNFα (~95%), IL-6 (~50%), IL-1β (~25%), and IL-10 (~20%), when compared with the placebo group. In addition, we determined that estradiol treatment restored cytosolic levels of NF-κB (65% increase) at the 24-hour time point. Also, estrogen decreased cytosolic accumulation of cytochrome C (50% reduction) at the 24-hour time point. Conclusions Following severe burn injury, estrogens decrease cardiac inlammation and levels of the pro-apoptotic cytochrome C. In addition, estrogen signaling promotes cell survival, as indicated by an increase in NF-κB levels. Importantly, estrogen treatment following burn injury nearly ablated the deleterious burn-induced increase of TNFα in the heart to levels similar to unburned control animals. Elevated cardiac levels of TNFα have previously been linked to a poor outcome. P585 Dexamethasone treatment during cardiac surgery and postoperative lactate levels SC Schuit, JJ Van Koesveld, AJ Bogers, J Bakker, RJ Van Thiel Erasmus MC, Rotterdam, the Netherlands Critical Care 2010, 14(Suppl 1):P585 (doi: 10.1186/cc8817) Figure 1 (abstract P583). Introduction Glucocorticoids are known to have an anti-insulin action on glucose metabolism, leading to increased lactate production [1]. Alternatively, glucocorticoid-induced apoptosis is a well-recognized phenomenon initiated by mitochondrial dysfunction [2]. Increased lactate production follows loss of mitochondrial membrane potential during apoptosis. Both mechanisms may lead to clinically relevant hyperlactatemia following glucocorticoid administration during cardiac surgery requiring cardiopulmonary bypass. Methods All adult patients undergoing cardiac surgery and cardiopulmonary bypass from 5 October through 21 November 2005 in a large academic teaching hospital in Rotterdam, the Netherlands were included in this study. Dexamethasone (60 to 80 mg) was given Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Figure 1 (abstract P585). Serum lactate levels in patients with and without dexamethasone during cardiopulmonary bypass. perioperatively at the discretion of the anesthetist. Lactate levels were measured within 1 hour postoperatively. The association between dexamethasone treatment, serum lactate levels and possible confounders was evaluated using ANOVA and linear regression. Results A total of 82 patients 18 years and older underwent cardiopulmonary bypass for cardiac surgery in the above-mentioned period. Three patients undergoing heart or lung transplantation, who thus received methylprednisolone, were excluded; a further two patients who received hydrocortisone for allergic reactions were also excluded. Data were incomplete for one patient, leaving a total of 76 patients for analysis. The mean lactate level was 1.2 mmol/l in the 47 patients who did not receive steroids and 2.6 mmol/l in the 29 patients who received dexamethasone (P <0.0001, Figure 1). When adjusting for potential confounders such as age, glucose level, duration of cardiopulmonary bypass and preoperative NYHA heart failure classiication, this diference remained signiicant (P <0.0001). Conclusions Administration of dexamethasone during cardiac surgery requiring cardiopulmonary bypass is associated with a signiicant hyperlactatemia. References 1. 2. Plager JE, et al.: Endocrinology 1966, 78:1154-1158. Distelhorst CW, et al.: Cell Death Dif 2002, 9:6-19. P586 Risk factors for hypertriglyceridemia in the intensive care unit: an exploratory study JC Devaud, P Voirol, P Marques-Vidal, L Tappy, N Rodondi, R Chiolero, MM Berger, A Pannatier University Hospital (CHUV), Lausanne, Switzerland Critical Care 2010, 14(Suppl 1):P586 (doi: 10.1186/cc8818) Introduction Despite guidelines recommending a daily fat intake of 0.7 to 1.5 g/kg/day in the ICU, subjects with hypertriglyceridemia >2 mmol/l (HTG) are common. As there are limited data on risk factors for HTG in the ICU, we aimed to determine the factors related with HTG in the ICU. Methods During 7 months, all consecutive patients staying ≥4 days in an adult ICU from a university hospital were enrolled. Patients eating regular meals or having an initiation or withdrawal of statin during their ICU stay were excluded. Peak values of triglycerides (TG) were collected and the relationships between log-TG and fat intake (g/kg/day) from nutritional (enteral and parenteral) and non-nutritional (propofol’s emulsion) sources as well as propofol (mg/kg/day) were assessed using Pearson’s correlation coeicients. Correlation was considered small for coeicients between 0.1 and 0.3 and medium for coeicients between 0.4 and 0.6. Nine groups of patients at risk of HTG were further compared with a control group (no risk factors for HTG) using Dunnett’s test (signiicant if adjusted P <0.05). S197 Results Of the initial 293 patients, 89 were excluded for eating regular meals or having an initiation or withdrawal of statin during their ICU stay. Of the remaining 204 patients, 79 (38.7%) had HTG, although guidelines for lipid intake were followed. Only three patients (1.5%) had a combined fat intake (enteral and parenteral) between 1.51 and 1.71 g/kg/day. Small positive correlations were observed with the intake of nutritional parenteral lipids (0.27), intake of all lipids given (0.20), intake of long-chain triglycerides (LCT) (0.15), and intake of parenteral LCT (0.20). Medium positive correlations were observed with the amount received of lipids administered with continuous propofol (0.40) and the amount of active principle of continuous propofol administered (0.42). In comparison with the control group (n = 81), patients with hepatic dysfunction (n = 6), pancreatitis (n = 14), severe insulin resistance (n = 2), sepsis (n = 32) and dyslipidemia without statin (n = 7) had signiicantly higher mean values of TG (all P <0.05). Groups with cirrhosis and ascites (n = 3), diabetes mellitus (n = 11), chronic renal failure (n = 6) and patients with statin before and during hospitalization (n = 42) had similar levels of TG as the control group. Conclusions When guidelines for fat intake in the ICU are followed, modest fat intake does not seem to explain HTG. Our results show that the amount of propofol given (mg/kg/day) and some clinical factors might be correlated with HTG in the ICU. P587 Septic patients show signiicantly lower 1,25-dihydroxy vitamin D levels than trauma patients A Cecchi1, S Douar1, S Paladini1, A Di Filippo2, M Ciapetti1, F Nencini1, M Andreani3, G Messeri1, M Bonizzoli1, J Parodo1, G Zagli1, A Peris1 1 Careggi Teaching Hospital, Florence, Italy; 2Institute of Anesthesia, University of Florence, Italy; 3Postgraduate School of Anesthesia and Intensive Care, University of Florence, Italy Critical Care 2010, 14(Suppl 1):P587 (doi: 10.1186/cc8819) Introduction It is known that 1,25-dihydroxyvitamin D (vitamin D) is involved in expression control of more than 200 genes. Vitamin D afects immunity, endothelial and mucosal functions as well as glucose and calcium metabolism. Moreover, its serum deiciency (<20 ng/ml) is reported to be common in hospitalized patients, especially among patients admitted to the ICU. Our aim was to evaluate vitamin D levels in a selected population of ICU patients and its correlation with admission pathology and outcome. Methods Among all patients admitted to our general ICU (February to October 2009), 84 patients were studied, 53 admitted for major trauma and 31 patients admitted for severe sepsis/septic shock. Exclusion criteria were: age <18 years, malnutrition state (BMI <18), pregnancy, breastfeeding, chemotherapy and immunotherapy, every pathology afecting bone and calcium metabolism, vitamin D metabolism derangements for therapies, haematological and solid malignancies, HIV. Vitamin D levels were measured by radioimmunoassay and registered at admission as well demographic data, simpliied acute physiology score (SAPS), injury severity score (ISS), length of stay (LOS), outcome. Data are expressed as the mean. Statistical analysis: Mann–Whitney (P <0.05). The study was approved by the Internal Review Board, which waived the need for informed consent. Results Vitamin D levels at admission to the ICU respectively were 14.1 ng/ ml in the sepsis group (age 61 years, SAPS 46.9) and 21.88 ng/ml in the trauma group (age 46.7 years, SAPS 36.2, ISS 26.8). To avoid the age-related bias, 23 patients older than 50 years were analysed. Vitamin D levels were found to be 20.9 ng/ml (mean age 66.6, SAPS 43.2, mean ISS 24) (P = 0.0195). No correlations with length of stay, duration of mechanical ventilation or outcome were found. Conclusions We conirm a vitamin D inadequacy among patients admitted to the ICU, even in young trauma patients (>20 and <30 ng/ml). However, septic patients showed a signiicantly lower vitamin D level than trauma patients with the same demographic/clinical characteristics (14.1 vs 20.9 ng/ml; P = 0.0195). Correlations between vitamin D levels, LOS and outcome need to be investigated with larger samples. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 S198 P588 High prevalence of severe vitamin D deiciency in intensive care patients JJ Weenink, H Oudemans-van Straaten, HT Yap, EH Slaats, PH Van der Voort OLVG hHospital, Amsterdam, the Netherlands Critical Care 2010, 14(Suppl 1):P588 (doi: 10.1186/cc8820) Introduction Vitamin D deiciency seems increasingly prevalent in the community, and deiciency has been reported in almost 60% of medical inpatients [1]. Pleiotropic efects of vitamin D like immunomodulation and efects on muscle strength may be of special importance to critically ill patients. Despite this knowledge, vitamin D deiciency has only been studied in small and selected groups of ICU patients [2]. Therefore, we prospectively determined the prevalence of vitamin D deiciency and related vitamin D status to outcome in a cohort of critically ill patients. Methods This prospective observational cohort study was performed in a 20-bed general ICU of a teaching hospital in the city of Amsterdam between 1 March and 30 April 2009. We measured 25-hydroxyvitamin D (25-OH-D) on admission and after 48 hours in all consecutive patients admitted to our unit. Patients received enteral feeding. Additional vitamin D was not supplied. Vitamin D status was deined as: adequate: >75 nmol/l, insuicient: 50 to 75 nmol/l, deicient: 25 to 50 nmol/l, severely deicient: <25 nmol/l, undetectable: <10 nmol (to convert values for 25-OH-D to ng/ml, divide by 2.50). We compared observed and predicted mortality (APACHE IV), and standardized mortality ratio (SMR, observed/predicted number of nonsurvivors) between vitamin D cohorts. Results Vitamin D was measured in 111 patients at admission and in 44 after 48 hours. Mean 25-OH-D at admission was 31 nmol/l. Thirteen percent of the patients had undetectable 25-OH-D levels, 49% was severely deicient and 85% had a vitamin D <50 nmol/l. Only two patients had an adequate 25-OH-D status. During the irst 48 hours of ICU admission, vitamin D decreased in 24 of 44 patients. Mean change was –2.3 nmol/l (range –32.5 to +22.5 nmol/l). Observed mortality was signiicantly lower than predicted in all patients (P = 0.02) and in patients with 25-OH-D >25 nmol/l (P = 0.04), but not in those <25 nmol/l (P = 0.21). See Table 1. Conclusions At the end of winter, one-half of our patients had severe vitamin D deiciency. In contrast to patients with severe deiciency, the cohort with vitamin D levels more than 25 nmol/l had a signiicant lower mortality than predicted by APACHE IV score. Measurements from a larger patient cohort are collected to further analyze this inding. References 1. 2. Thomas MK et al.: N Engl J Med 1998, 338:777-783. Lee P: N Engl J Med 2009, 360:1912-1914. P589 Vitamin D, parathyroid hormone and serum calcium levels and their association with hospital mortality in critically ill patients K Amrein, S Amrein, A Holl, A Waltensdorfer, TR Pieber, H Dobnig Medical University of Graz, Austria Critical Care 2010, 14(Suppl 1):P589 (doi: 10.1186/cc8821) Introduction Vitamin D deiciency is highly prevalent and has been associated with increased mortality in the general population [1,2]. Critically ill patients are especially prone to present with or develop low vitamin D levels due to their underlying disease, sunlight deprivation or longer hospital stays. Methods Parathyroid hormone (PTH) and vitamin D status (25-hydroxyvitamin D (25(OH)D)) were assessed at diferent ICUs (medical, cardiac surgery, mixed surgical and neurological) in 404 patients (age 63 ± 16 years, 65% male) from September 2008 until November 2009. Results The mean serum 25(OH)D level was 19.6 ± 11.2 ng/ml. Normal 25(OH)D levels (>30 ng/ml) were found in 12.4% of all patients. The majority (58.2%) were vitamin D deicient (<20 ng/ml), while 29.4% were considered vitamin D insuicient (>20 and <30 ng/ml) by current deinitions. Signiicant variations of vitamin D levels occurred depending on season, with highest values found in August (27.1 ± 13.1 ng/ml) and the lowest in March (12.5 ± 4.6 ng/ml), respectively. Secondary hyperparathyroidism (PTH >65 pg/ml) was highly prevalent in medical and cardiac surgery patients (43.7% and 37.9%). In an age, sex and SAPS II score adjusted Cox-proportional hazards regression analysis model, patients with low PTH or serum calcium levels, as well as low 25(OH)D levels (cut-of 12 ng/ml) were all at signiicantly greater risk for all-cause mortality. With all variables included into one model (n = 268 patients) serum calcium remained an independent predictor of mortality, whereas PTH log (P = 0.08) and 25(OH)D (P = 0.16) levels suggested a trend. Conclusions Vitamin D deiciency is often encountered in critically ill patients. Higher than the currently recommended daily dose of 200 IU vitamin D3 is probably required for achieving or maintaining normal 25(OH)D levels. Results of this study suggest that baseline parameters relecting calcium/PTH status are associated with mortality. Whether a disturbance in calcium/vitamin D3 or PTH metabolism develops secondary to the medical condition of ICU patients or is a primary cause of mortality remains to be clariied in prospective analyses. References 1. 2. Dobnig H, et al.: Arch Intern Med 2008, 168:1340-1349. Melamed ML, et al.: Arch Intern Med 2008, 168:1629-1637. P590 Efect of restoration of 25OHD3 status in prolonged critical illness on serum innate immunity parameters LL-37 and sCD163 CM Ingels1, SJ Van Cromphaut1, PJ Wouters1, HJ Moller2, E Van Herck1, I Jans1, R Bouillon1, G Van den Berghe1 1 University Hospitals Leuven, Belgium; 2Aarhus University, Aarhus, Denmark Critical Care 2010, 14(Suppl 1):P590 (doi: 10.1186/cc8822) Introduction We previously observed that critically ill patients are vitD deicient. This status cannot be restored by increasing the normally recommended intravenous vitD dose. The antimicrobial peptide LL-37 is expressed in macrophages upon stimulation by 25OHD3. sCD163 is a soluble pattern-recognition receptor, which is a marker of macrophage activation and a predictor of mortality in SIRS. The aim of this study is to unravel the impact of 25OHD3 deiciency and normalization on innate immunity parameters – CRP, LL-37 and sCD163 – in critical illness. Methods We randomly allocated patients upon ICU admission to receive either placebo (n = 13) or a 10-day treatment of 15 μg/day 25OHD3 intravenously after a loading dose of 200 μg intravenously (n = 11) on top of the normal vitD dose (200 IU). Patients with chronic bone or kidney disease, glucocorticoid treatment, age younger than 18 years, or with an anticipated ICU length of stay less than 10 days were excluded. On admission, patients were compared with healthy age-matched, gendermatched and BMI-matched controls (n = 24). Results Administration of the 25OHD3 regimen resulted in a rapid and sustained increase of serum 25OHD3 levels (P <0.05 vs placebo). 1,25(OH)2D3 levels rose only transiently (P = 0.07 on day 1, P = 0.08 on day 2 vs placebo). 25OHD3 and 1,25(OH)2D3 levels were lower than those of healthy controls (sampled during summer). 25OHD3 treatment had no signiicant efect on CRP. On admission, LL-37 levels (26 ± 6 μg/l) were comparable with those of healthy controls (22 ± 2 μg/l). The treatment tended to transiently increase LL-37 levels (change from baseline: P = 0.1 on day 6 vs placebo). Serum sCD163 levels tended to be higher at baseline Table 1 (abstract P588) Number of patients Age (years) Hospital mortality (%) APACHE IV p.m. (fraction) SMR (fraction) All patients 111 67 19 0.31 0.61 (0.38 to 0.93a) 25-OH-D <25 nmol/l 54 68 24* 0.34 0.71 (0.38 to 1.21a) 25-OH-D >25 nmol/l 57 67 14 0.29 0.48 (0.21 to 0.92a) a 95% conidence interval (Fischer’s exact). *P = 0.33 compared with >25 nmol. p.m., predicted mortality. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 (P = 0.06 vs healthy controls) and rose signiicantly over time (P <0.05 on day 5 and on day 10 vs day 0) but were not inluenced by the treatment. Conclusions The preliminary results of this randomized placebocontrolled pilot study indicate that, in contrast to a high intravenous 500 IU vitD supplement, intravenous 25OHD3 treatment resulted in an immediate and persistent increase in serum 25OHD3, but did not afect 1,25(OH)2D3 levels. Plasma LL-37 alterations in the studied prolonged critically ill patients hints at ameliorated LL-37 production provided that the 25OHD3 status is restored. Serum sCD163 and CRP levels evolved during the ICU stay, but were not signiicantly altered by 25OHD3 supplementation. The results of this pilot study warrant further research into the potential modulation of innate immune processes by 25OHD3 in the critically ill. P591 Alterations in adipose tissue during critical illness: an adaptive and protective response? L Langouche1, S Vander Perre1, S Thiessen1, G Hermans1, A D’Hoore1, B Kola2, M Korbonits2, G Van den Berghe1 1 KU Leuven, Belgium; 2Barts and the London School of Medicine and Dentistry – Queen Mary University of London, UK Critical Care 2010, 14(Suppl 1):P591 (doi: 10.1186/cc8823) Introduction Critical illness is characterized by lean tissue wasting whereas adipose tissue is preserved. Obese critically ill patients may have a lower risk of death than nonobese patients, a recent observation that may suggest a protective role for adipose tissue during illness, a role which has not been previously investigated. We hypothesized that adipose tissue could function as a waste bin for potentially toxic metabolites, such as glucose, during critical illness. Methods We studied adipose tissue biopsies from 61 of critically ill patients, more speciically morphology and the potential to take up and metabolize glucose, and compared this with biopsies from 20 matched controls. Results Adipose tissue biopsies from critically ill patients revealed a higher number and a smaller size of adipocytes as compared with matched controls, coinciding with increased preadipocyte marker levels. Also, >95% of adipose biopsies from critically ill patients displayed positive macrophage staining. Gene and protein expression of insulin-independent GLUTs, and tissue glucose content was increased. Glucokinase expression was upregulated whereas glycogen and glucose-6-phosphate levels were low. Acetyl-CoA-carboxylase protein level and activity of fatty-acid synthase were increased. A substantially increased activity of AMPK may play a crucial role. Conclusions The larger number of small adipocytes in response to critical illness appears to have an increased ability to take up and metabolize glucose into fatty acids. Such changes may render adipose tissue biologically active as a functional waste bin for toxic metabolites during critical illness, which could contribute to survival. P592 Impact of collection method and sample handling on measured levels of circulating ACTH C Borin, D Mesotten, G Van den Berghe, H Vervenne KU Leuven, Belgium Critical Care 2010, 14(Suppl 1):P592 (doi: 10.1186/cc8824) Introduction Cortisol, which is produced and released by the adrenal gland under the regulation of the adrenocorticotropic hormone (ACTH), plays a crucial role in the survival mechanisms involved in critical illness. A dissociation between high plasma cortisol and low ACTH in patients has been observed in the more chronic phase of critical illness induced by severe sepsis and multiple trauma [1]. In order to assess the potential confounding impact of errors in the measurement of ACTH, we evaluated the stability of ACTH during sample processing. Methods Two tests were performed. For the irst test, two blood samples per patient were taken from 10 randomly selected patients in the surgical ICU. One sample was collected warm (that is, samples were collected at room temperature (RT), left for 60 to 90 minutes at RT followed by S199 24 hours at 4°C, centrifuged (10 minutes, 1,000 rpm), and serum was stored at –80°C), the other sample was collected cold (that is, recommended collection procedure for ACTH detection: samples were collected on ice, centrifuged (10 minutes, 1,000 rpm), and plasma was stored at –80°C). For a second test, again, two blood samples were taken per patient (n = 10) in the surgical ICU. One sample was kept frozen until ACTH testing (original), whereas the other sample was defrosted several times at RT before analysis (defrosted). ACTH levels were measured using an ACTH RIA kit (BRAHMS) and the diferent sampling methods and sample treatments were compared using Bland–Altman statistics. Results No clinically relevant diferences in ACTH levels were observed between cold (28.2 ± 22.3 pg/ml) and warm (24.3 ± 20.6 pg/ml) sampling (bias 3.8 ± 7.3 pg/ml) or between original (22.1 ± 10.8 pg/ml) and defrosted (22.3 ± 10.5 pg/ml) samples (bias 0.2 ± 1.9 pg/ml). Moreover, the diferences in ACTH levels measured between the two collection methods or sample treatments were independent of the amount of ACTH present in the samples. Conclusions We showed that warm collection or frequent defrosting of samples does not induce a clinically signiicant error in ACTH levels measured, implying that nonideally collected or treated samples can still be used for rough ACTH analysis. Reference 1. Vermes et al.: J Clin Endocrinol Metab 1995, 80:1238-1242. P593 Prognostic value of serum zinc levels in critically ill patients B Cander, D Dundar, M Gul, S Girisgin Selcuk University Meram Faculty of Medicine, Konya, Turkey Critical Care 2010, 14(Suppl 1):P593 (doi: 10.1186/cc8825) Introduction Zinc is a trace element that is required for normal function of many enzymes. Intact zinc homeostasis must be present for normal function of the immune system, oxidative stress responses. We explored the hypothesis that a decline in serum zinc concentrations among critically ill patients is related to mortality, length of stay in the ICU, APACHE II and SOFA scores. Methods This prospective study was conducted in the ICU of the emergency department. All patients (>18 years) admitted to the ICU from September through November 2009 were enrolled into the study. Burn victims, alcoholics, patients with gastrointestinal istulas and severe diarrhea were excluded from the study. Patients’ demographic characteristics, APACHE and SOFA scores were recorded; blood samples were collected within 24 hours after admission and analyzed for serum zinc, copper, C-reactive protein and albumin levels. Patients were followed up for mortality and length of stay in the ICU for 28 days. Results Thirty-six patients were enrolled during the study period, with median age 70.5 years (18 to 87). The male to female ratio was 1:1.1. Serum zinc levels correlated inversely with SOFA scores (r = –0.41, P = 0.01). Patients with ≥8 SOFA scores had signiicantly lower serum zinc levels compared with patients with <8 SOFA scores (6.74 ± 1.63 μmol/l (n = 11) and 9.17 ± 2.76 μmol/l (n = 25), respectively; P <0.05). There was no signiicant diference between serum zinc levels of patients with <25 and ≥25 APACHE II scores and also there was no signiicant diference between survivors and nonsurvivors. Serum zinc and copper levels had no signiicant relationship with length of stay in the ICU. Conclusions Serum zinc concentrations correlated inversely with SOFA scores in this study. This result supports that organ failure and critical illness leads to a decline in serum zinc concentrations and that zinc administration may be beneicial for critically ill patients. References 1. 2. 3. Cvijanovich NZ, et al.: Zinc homeostasis in pediatric critical illness. Pediatr Crit Care Med 2009, 10:29-34. Berger MM, et al.: Trace element requirements in critically ill burned patients. J Trace Elem Med Biol 2007, 21(Suppl 1):44-48. Heyland DK, et al.: Zinc supplementation in critically ill patients: a key pharmaconutrient? J Parenter Enteral Nutr 2008, 32:509-519. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P594 High stress during admission predicts the impact of a PICU follow-up clinic on parents’ psychological outcome G Colville, P Cream, S Kerry St George’s Hospital, London, UK Critical Care 2010, 14(Suppl 1):P594 (doi: 10.1186/cc8826) Introduction There are no formal reports of follow-up services in pediatric intensive care settings despite mounting evidence that parents report negative psychological symptoms for many months after a child’s admission to the pediatric intensive care unit (PICU). The aim of this study was to establish the impact of a PICU follow-up clinic on parents’ distress. Methods In this prospective, randomised controlled trial, parents of 133 children admitted to an eight-bed PICU for >12 hours were randomly allocated to either the intervention (follow-up clinic appointment ofered 2 months after discharge) or control (no appointment) condition. Parents’ baseline stress was assessed at discharge using the Parental Stressor Scale: PICU [1]. Five months later, post-traumatic stress, anxiety and depression were assessed by postal questionnaires (Impact of Event Scale [2] and Hospital Anxiety and Depression Scale [3]). Results Outcome data were obtained for 105 parents. Whole group analyses revealed no signiicant diferences in psychological outcome between the control and intervention groups. However, post hoc analyses revealed efects in favour of the intervention, for a sub-group of parents (n = 55) who had reported baseline stress scores above median during their child’s hospitalisation. Within this sub-group, parents who received the intervention were less likely to report clinically signiicant levels of post-traumatic stress symptoms (25% vs 56%, P = 0.018) or depression (19% vs 52%, P = 0.009) than controls. Conclusions Whilst these results do not justify routine provision of PICU follow-up clinic appointments for all parents, they do suggest that rates of long-term distress in those who ind the admission particularly traumatic could be reduced by a simple one-of intervention, which was feasible in a clinical setting. References 1. 2. 3. Carter MC, Miles MS: The Parental Stressor Scale: Pediatric Intensive Care Unit. Matern Child Nurs J 1989, 18:187-198. Horowitz M, Wilner N, Alvarez W: Impact of Event Scale: a measure of subjective stress. Psychosom Med 1979, 41:209-218. Zigmond AS, Snaith RP: The hospital anxiety and depression scale. Acta Psychiatr Scand 1983, 67:361-370. P595 Patient’s contact person in the intensive care unit: is it really important? AH Nielsen, CB Kancir Regional Hospital West Jutland, Holstebro, Denmark Critical Care 2010, 14(Suppl 1):P595 (doi: 10.1186/cc8827) Introduction The concept of a patient’s contact person was originally introduced in Denmark as a political goal. It was elevated into law in 2009. As an integrated part of the Danish Healthcare Quality Program, Danish hospitals must have programs allowing each patient a contact person, who should take an active part in treatment and care. However, the concept is still not well implemented on a broader scale. Implementing a patient’s contact person concept in an ICU produces new obstacles. The ICU difers from other clinical settings in various ways. It is heavier stafed at all hours. The number of doctors is limited and nurses perform primary care. Each staf member has good insight in all patient cases, which are discussed at the daily conferences. So, is the patient’s contact person really important in the ICU? Methods Questionnaires were handed out to the close relatives of every patient who stayed more than 72 hours in the ICU. Ninety-four questionnaires have been returned with usable data. No attempt to retrieve questionnaires from nonrespondents has been made. All were returned in marked envelopes, the questionnaire itself being unmarked. The questionnaire contained two questions on the patient’s contact person: 1. In your experience, did you have a contact person? 2. Do you think there is a need for a contact person? Both questions were simple yes/no answers, with the possibility of adding comments. The analysis focused on quantity and quality, as displayed in the remarks made. S200 Results The median age of the respondents was 56 years (range 27 to 81 years). On the irst question, whether you had a contact person, 40 answered Yes and 54 No. On the second question, whether there is a need for a contact person, 55 answered Yes, 31 No and eight did not answer. Twenty-six and 23 answered respectively Yes and No in both questions. Analyzing the comments made on whether you had a contact person, a diferent picture emerges. Of 39 comments, four are indiferent and 35 are positive – feeling that they have been met in a competent and caring manner. The comments made on whether there is a need for a contact person relect an important discussion: some wish for a contact person, arguing that it will make them feel safer when in distress. Others point out that it would be diicult and that the contact person might not be available when needed due to the rotation shift work of nurses and doctors. Conclusions This study shows that there is still a place and need for improvement in the concept of a patient’s contact person. P596 Evaluating the quality of communication with patients’ relatives in critical care S Siddiqui, C Scott, D Bryden Northern General Hospital, Sheield, UK Critical Care 2010, 14(Suppl 1):P596 (doi: 10.1186/cc8828) Introduction Good communication with patients’ relatives has humanitarian, professional and medico-legal beneits. The NHS Litigation Authority requires clear information documentation and monitoring that this is satisfactory [1]. This review was performed to ascertain relatives’ opinions regarding the current standard of communication received from medical staf. Methods A paper questionnaire was made available to relatives after discussion with a member of the medical staf. Data for the irst month are discussed below, based on an average 50 admissions/month. The questionnaire was at the main reception desk, and staf also ofered them to relatives after each professional contact. Closed questions with single answers chosen from ive options (including one neutral option) were asked along with space for free comment. Results Eighteen questionnaires were completed: to our knowledge no relatives refused completion. Thirteen out of 18 discussions took place between 8 am and 6 pm, Monday to Friday, three between 8 pm and 6 am weekdays, and two at the weekend. All 18/18 respondents felt the doctor had explained their role in care. Thirteen out of 18 discussions took place in the dedicated interview room, four at the bedside and one by telephone. Seventeen out of 18 rated the service as very good for information given, clarity and the efect of the exchange on overall impressions of care; one questionnaire rated the service as good. Conclusions Relative communication is highly subjective but is known to inluence impressions formed of overall quality of care. National audit frameworks emphasise objective quantiiable standards, which do not capture the quality of interaction [2]. We have monitored service quality based on subjective relative impressions, however the response rate (<40%) has potential for a positive bias in our favour. Many discussions are complex and there is a possibility that questionnaires were not ofered in certain situations. Additionally, despite full anonymity of the form, relatives may have been concerned about what was written impacting on their family member’s care. It is known that beneits in the processes of clinical care leading to improvements in quality can arise purely from measurement; that is, performing service reviews such as this one [3]. If targets are to be used to benchmark quality of care in this area, there is a need for more consideration of the appropriate targets or alternatively an acceptance that there is the potential to have lower data capture in these areas. References 1. 2. 3. NHSLA Risk Management Standards [http://www.nhsla.com/NR/rdonlyres/ EC2E2A20-C905-4A4A-9D71-AF989F736C7B/0/Introductiontomanual.pdf ] Humble SR et al.: Intensive Care Med 2007, 33:S209. Wright J, Shojania KG: Br Med J 2009, 38:783-784. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 P597 Family satisfaction on the intensive care unit C Meadows, A Bastin, S Kaul, S Finney Royal Brompton Hospital, London, UK Critical Care 2010, 14(Suppl 1):P597 (doi: 10.1186/cc8829) Introduction Patient satisfaction data collation is a priority for the UK’s Care Quality Commission. In the adult intensive care unit (AICU), patients are often sedated for prolonged periods. Family satisfaction data may be useful to gauge quality of service delivery. The Family Satisfaction-ICU (FS-ICU 34) questionnaire was developed and validated in the USA [1]. To our knowledge, we are the irst group to use it in the UK. Methods The FS-ICU 34 is an anonymised questionnaire. We adapted the American terminology for use in the UK. Inclusion criteria were: AICU admission of 5 days or more; presence of next-of-kin. Patients who died were excluded. It was handed personally to AICU patients’ next-of-kin following discharge. Nursing staf from both the AICU and general wards assisted in returning completed questionnaires. Key areas of questioning using the FS-ICU were: perception of treatment of patient discomfort; coordination of AICU services; skill and competencies of AICU staf ; consistency and frequency of communication; standard of family facilities; and emotional support. Relatives were asked to grade their answers on a ive-point scale (excellent to poor). Results Data from the irst 4 months of this survey have now been analysed. One hundred per cent of patients’ relatives who fulilled the inclusion criteria received a questionnaire. The response rate was 68%. The majority of respondents were satisied with overall care and decision-making. Similarly to published data [2], families were most satisied with nursing skill and competence (94.7% satisied), and least satisied with waiting room atmosphere (42.4%) and frequency of communication with doctors (71.2%). Conclusions The FS-ICU has enabled us to identify and target resources at key aspects of our service delivery. It has presented an opportunity for us to address misunderstandings and misconceptions regarding the ICU within our client base. This survey is unique in examining the links the ICU has with the community and informs the process of understanding that relationship. References 1. 2. Wall et al.: Crit Care Med 2007, 35:271-279. Heyland et al.: Crit Care Med 2002, 30:1413-1418. P598 Survey into bereavement of family members of patients who died in the intensive care unit L Heijboer1, J Van der Klink1, J Hofhuis1, A Hovingh1, J Rommes1, M Westerman2, P Spronk1 1 Gelre Hospitals, Apeldoorn, the Netherlands; 2VU University, Amsterdam, the Netherlands Critical Care 2010, 14(Suppl 1):P598 (doi: 10.1186/cc8830) Introduction The death of a family member in the ICU is often sudden and unexpected and may have a strong impact. The care provided in the ICU difers from other hospital settings, resulting in special needs for family members of the dying patient. We studied the characteristics of bereavement, the need for follow-up bereavement service and to determine whether the information and care in the ICU is suicient for relatives of deceased ICU patients. Methods A structured telephone interview was conducted in a 10-bed mixed medical–surgical ICU. Patients and respondents were selected according to four criteria: (1) the patient had died between June 2008 and June 2009 in the ICU, (2) there had to be at least one relative, who (3) was involved during the ICU stay preceding death and (4) had suicient knowledge of the Dutch language. For each deceased patient, one family member was identiied as eligible for study participation. All eligible family members were irst contacted by an ICU nurse to ask for agreement with the study. Furthermore, the structured interview was then emailed or sent to the family members so they would be able to read the questionnaire prior to the actual telephone interview. Three weeks after the initial telephone call by the nurses, the respondents were contacted for the structured telephone interview with speciic attention to the use of new medication, work-related problems, resuming normal activities, money problems and sleeping problems. S201 Results A substantial portion of the respondents (37%) complained about sleeping problems. A majority (77%) was satisied with the provided ICU care and the information provided. Almost all of the respondents (90%) understood the fatal sequence of events during the dying process. Most common complaints concerned communication and the information provided. The need for a follow-up bereavement service was reported by 35% of the respondents. Reasons for such a service were irstly to deal with the death of the family member and secondly to answer remaining questions. Conclusions This study demonstrates that most relatives had resumed their normal activities. In addition, there was a high level of satisfaction with the care provided in the ICU, although many considered a followup bereavement service potentially useful. The most frequent persisting bereavement characteristic was related to sleeping problems. P599 Exploration of the needs and experiences of family members of a patient being admitted to a neurosurgery intensive care unit in Shiraz, Iran S Gholamzadeh1, S Gholamzadeh2, H Sorbi Akbari3 1 Fatemeh Nursing College, Shiraz, Iran; 2Fars Medical Legal Organization, Darab, Iran; 3Private Medical Oice, Darab, Iran Critical Care 2010, 14(Suppl 1):P599 (doi: 10.1186/cc8831) Introduction Sudden hospitalization of a relative to a critical care setting is a catastrophic event for families. Nurses may not always assess the needs of relatives the way they themselves experience their needs to provide support. This qualitative study was conducted to explore the experiences of relatives of patients in adult neurosurgery ICUs in Shiraz, Iran. Methods In this qualitative study, grounded theory was used to explore the experiences of 10 relatives of patients in neurosurgery ICUs. The data consisted of in-depth interviews and participant and nonparticipant observation. All data were recorded by writing in a notebook, and subsequent listening to the audio recordings and reading through the transcription of each interview was done. Results Five major categories emerged from the data: information seeking, vigilant attendance, intense emotion, need for respect, and need to care about patient privacy. The most important needs of relatives were to have information about the condition of their loved one, talk to a doctor and their questions are answered honestly. The other theme was vigilant attendance. Many informants pointed out that they were willing to stay continuously inside the ICU to see what is going on and they wanted lexible open visiting. Also relatives showed the sufering they experience and their needs for support and empathy. The study also deined two new concepts in this area: need for respect and care about patient privacy. Conclusions It is essential that intensive care nurses are able to identify the speciic needs of family members to provide appropriate supportive interventions. References 1. 2. Engli M, Kirsivali-Farmer K: Needs of family of critically ill patients with and without acute brain injury. J Neurosci Nurs 1993, 25:78-85. Curry S: Identifying family needs and stresses in the intensive care unit. Br J Nurs 1995, 4:15-19. P600 Deciding the end of life for patients with disorders of consciousness: a European survey A Demertzi1, D Ledoux1, MA Bruno1, A Vanhaudenhuyse1, O Gosseries1, A Soddu1, M Boly1, C Schnakers1, G Moonen2, S Laureys1 1 Cyclotron Research Center, University of Liege, Belgium; 2CHU, Liege, Belgium Critical Care 2010, 14(Suppl 1):P600 (doi: 10.1186/cc8832) Introduction Withdrawal of artiicial nutrition and hydration (ANH) is ethically justiied for patients with irreversible disorders of consciousness (coma, vegetative (VS), minimally conscious state (MCS)) [1]. However, the absence of deinite ethical steps within the medical community makes objective end-of-life decisions diicult to take. The present survey aims to debrief attitudes towards end-of-life decisions in these patients in order to facilitate future guidelines. Critical Care 2010, Volume 14 Suppl 1 http://ccforum.com/supplements/14/S1 Methods A 16-item questionnaire around various issues on consciousness was presented to attendees at conferences in Europe. Data were obtained from 3,672 respondents (M age 36 ± 16 years, range 14 to 88; 55% women; 34 EU countries) and were analyzed with SPSS v. 16.0. Results Sixty-seven percent (n = 2,454) agreed with ANH withdrawal in chronic VS (31%, n = 1,138 disagreed; 2%, n = 80 no response). A signiicant agreement was expressed by nonreligious respondents (vs religious; B = 0.70, P <0.001) and nonmedical professionals (vs doctors; B = 0.34, P = 0.001). Signiicant disagreement was expressed by women (vs men; B = –0.25, P = 0.004), central and south Europeans (vs northern; B = –0.85, P <0.001 and B = –1.23, P <0.001, respectively) and those of higher age (B = –0.008, P = 0.01). Eighty percent (n = 2,956) did not wish to stay alive if themselves were in a permanent VS (18%, n = 625 wished to stay alive; 2%, n = 64 no response). Seventy-eight percent considered that being in permanent VS is worse than death for the patient’s family (55% considered it worse than death for patients themselves). Sixty-nine percent (n = 2,523) disagreed with ANH withdrawal in chronic MCS (29%, n = 1,073 agreed; 2%, n = 76 no response). A signiicant disagreement was expressed by central and south Europeans (vs northern; B = –0.58, P <0.001 and B = –1.3, P <0.001, respectively) and respondents of higher age (B = –0.007, P = 0.019); a signiicant agreement was expressed by non-religious respondents (vs religious; B = 0.65, P <0.001). Sixty-four percent (n = 2,355) did not wish to be kept alive if themselves were in a permanent MCS (34%, n = 1,248 wished to stay alive; 2%, n = 69 no response). Forty percent considered that being in a MCS is worse than VS for the patient’s family (50% considered it worse than VS for patients themselves). Conclusions These indings raise important ethical issues concerning our care for patients with chronic disorders of consciousness. In light of high rates of diagnostic error in these patients [2], the necessity for adapted standards of care is warranted. References 1. 2. Royal College of Physicians: Clin Med 2003, 3:249-254. Schnakers C, et al.: BMC Neurol 2009, 9:35. P601 Evaluation of a new limitations and withdrawal of care framework order form in the intensive care unit PB Sherren, L Turnbull, S Yoganathan Queens Hospital, Romford, UK Critical Care 2010, 14(Suppl 1):P601 (doi: 10.1186/cc8833) Introduction The aim of this study was to demonstrate improvements in both staf and patient experiences with end-of-life care. The ICU is a setting where death is common; it has been suggested that 20% of patients in the US die on the ICU [1]. Given that the majority of ICU deaths involve the withholding or withdrawing of treatment [2], the importance of end-of-life care is clear. Despite this frequency, studies suggest that the current quality of end-of-life care is suboptimal on the ICU [3,4]. As a result, we developed a new framework to address this issue. Methods We introduced our new framework over a 1-year period; we circulated questionnaires to the staf pre and post study to demonstrate any improvements in end-of-life care. Results Our framework was found to be helpful by 97% of respondents and was associated with an improvement in communication and knowledge of end-of-life care. We discovered an increase in the number of staf who felt that patients, along with having their analgesia/sedation needs met, were now experiencing care that was more conducive to a good quality of dying. The number of staf who now felt conident in managing withdrawal of care trended towards a signiicant P value. See Figure 1 for details. Conclusions Quality of end-of-life care was improved with our new framework; however, further research is vital to ensure our patients receive the same kind of evidence-based medicine in their inal hours as they did during their acute illness. References 1. 2. 3. 4. Angus DC, et al.: Crit Care Med 2004, 32:638-643. Wood GG, et al.: Can J Anaesth 1995, 42:186-191. Desbiens NA, et al.: J Am Geriatr Soc 2000, 48:S183-S186. Treece PD, et al.: Crit Care Med 2004, 32:1141-1147. S202 Figure 1 (abstract P601). P602 End-of-life decisions in Hungarian intensive care units L Zubek, G Élő, L Szabó Semmelweis University, Budapest, Hungary Critical Care 2010, 14(Suppl 1):P602 (doi: 10.1186/cc8834) Introduction The acknowledgement of local practice with respect to endof-life decisions in accordance with laws and ethical principles is inevitable for intensive physicians in all countries. The irst step for the required social dialogue is to search for local customs for harmonisation with ethical and legal regulations, as well as the interests of physicians and patients. Methods In 2007 we performed the irst Hungarian survey with the purpose to learn more about the local practice of end-of-life decisions. Questionnaires were sent out electronically to 743 registered members of the Hungarian Society of Anaesthesiology and Intensive Care. Respecting anonymity we have statistically evaluated 103 replies (response rate was 13.8%) and compared with data from other European countries. Results As expected, it turned out from the replies that the practice of domestic intensive care physicians is very paternal and this is promoted by legal regulations that share a similar character. Intensive care physicians generally make their decisions alone (3.75/5 points) without respecting the opinion of the patient (2.57/5 points), the relatives (2.14/5 points) or other medical personnel (2.37/5 points). Furthermore they prefer not to start a therapy rather than withdraw an ongoing treatment. Nevertheless, the frequency of end-of-life decisions (3 to 9% of ICU patients) is similar to other European countries. Conclusions Hungarian intensive care physicians make end-of-life actions routinely. They usually decide based on their own opinion, slightly considering the opinion of nursing personnel, the patients or their relatives. They are not supported by the Hungarian legal regulation in making these decisions. Although the living will and the advanced directive are both acknowledged, they are not as widespread as required. Our study is the irst step to commence a social dialogue, which is taken in the evolution of end-of-life decision-making procedures. References 1. 2. 3. Van der Heide A, et al.: End of life decision making in six European countries: descriptive study. Lancet 2003, 362:345-350. Sprung CL, et al.: End-of-life practices in European intensive care units; the Ethicus Study. JAMA 2003, 290:790-797. Vincent JL: Forgoing life support in western European intensive care units: the results of an ethical questionnaire. Crit Care Med 1999, 27:1626-1633. Cite abstracts in this supplement using the relevant abstract number, e.g.: Zubek L, Élő G, Szabó L: End-of-life decisions in Hungarian intensive care units [abstract]. Critical Care 2010, 14(Suppl 1):P602.