Proceedings of Réanimation 2017, the French Intensive Care Society International Congress

Physician abstractsOral communicationsO1 Pulmonary embolism related sudden cardiac arrest admitted alive at hospital: characteristics and outcomesWulfran Bougouin1, Eloi Marijon1, Benjamin Planquette2, Nicole Karam1, Florence Dumas3, David Celermajer4, Daniel Jost5, Lionel Lamhaut6, Frankie Beganton7, Alain Cariou8, Guy Meyer9, Xavier Jouven10, Sudden Death Expertise Center 1Cardiologie, Hôpital Européen Georges-Pompidou, Rue Leblanc, Paris, France; 2Usip, Hopital Europeen Georges-Pompidou, Paris, France; 3Service d'accueil des urgences, Hôpital Cochin, Paris, France; 4Cardiology, Sydney medical school, Sydney, Australia; 5Bspp, B.s.p.p., Paris, France; 6Réanimation adulte, Hôpital Necker - Enfants Malades, Paris, France; 7Paris descartes, Inserm U970, Paris, France; 8Réanimation Médicale, Hôpital Cochin, Paris, France; 9Service de Pneumologie et Soins Intensifs, Hopital Europeen Georges-Pompidou, Paris, France; 10Cardiologie, Hôpital Européen Georges-Pompidou, Paris, France Correspondence: Wulfran Bougouin - wulfran.bougouin@gmail.com Annals of Intensive Care 2017, 7(Suppl 1):O1 Introduction Pulmonary embolism (PE) is a relatively common cardiovascular condition, occasionally and tragically manifesting as sudden cardiac arrest (SCA). The natural history of SCA complicating PE has been poorly evaluated. Guidelines suggest the consideration of thrombolytic therapy when PE-related SCA is suspected, despite the absence of evidence. In this study, we described the characteristics and management of PE-related SCA in a large regional registry. Patients and methods In this prospective population-based study, we included all patients admitted at hospital alive after out-of-hospital SCA, in Paris and suburbs, France (6.6 million inhabits), from May 2011 to September 2015. Regarding PE, we collected risk factors, clinical decision rules (Wells rule and Geneva score) and diagnostic strategy. Results Of 2926 patients hospitalized after SCA, 82 cases were diagnosed as PE-related SCA (2.8%, 95% CI 2.2–3.4). Independent factors associated with SCA due to PE were non-shockable initial rhythm (OR 12.4, 95% CI 4.9–31.0, P < 0.001), past history of thromboembolism (OR 10.4, 95% CI 5.6–19.4, P < 0.001), absence of known heart disease (OR 3.8, 95% CI 2.0–7.3, P < 0.001) and female sex (OR 1.9, 95% CI 1.2–3.0, P = 0.008). Considering non-shockable initial rhythm and previous thromboembolism as major predictors of PE, combination of those factors had a specificity for detection of PE-related SCA of 98% and a sensitivity of 23%, with a positive predictive value of 31% and a negative predictive value of 98% (Fig. 1) .Fig. 1See text for descriptionFull size image Systemic thrombolysis was performed in 47 patients (57%). After adjustment, PE was associated with survival at discharge (OR 2.4, 95% CI 1.2–4.7, P = 0.001), compared with non-PE SCA. Finally, among patients hospitalized for PE-related SCA, only thrombolysis (OR 12.5, 95% CI 1.8–89.1, P = 0.01) and delay from CPR to ROSC < 20 min (OR 6.8, 95% CI 1.3–35.2, P = 0.02) were independently associated with survival to hospital discharge. Conclusion In this population-based study, PE was not an unusual cause of SCA, and was associated with better survival, challenging the traditional view. Thrombolysis was associated with an increased survival in this population, reinforcing current guidelines. Competing interests None.O2 Eligibility for and feasibility of donation after circulatory death Maastricht III (DCD MIII) process in post-anoxic patients: a retrospective analysisCôme Bureau1, Julien Charpentier1, Omar Ben Hadj Salem1, Lucie Guillemet1, Michel Arnaout1, Matthieu Jamme1, Alexis Ferre1, Guillaume Geri1, Florence Dumas1, Nicolas Mongardon1, Frédéric Pène1, Jean-Daniel Chiche1, Jean-Paul Mira1, Alain Cariou1 1Réanimation médicale, Hôpital Cochin, Paris, France Correspondence: Côme Bureau come.bureau@gmail.com Annals of Intensive Care 2017, 7(Suppl 1):O2 Introduction Donation after circulatory death corresponds to the category III of the Maastricht classification (DCDM III) and may provide mostly kidney and liver transplants with good long-term function. Patients suffering from irreversible brain damages after cardiac arrest are commonly considered candidates for DCDMIII, but little is known regarding the proportion of these patients who could be eligible for this procedure. Using a cohort of post-cardiac arrest patients, our aim was to assess the rate of contra-indications for DCDMIII and to measure the delay between withdrawal of life sustaining treatments (LSTW) and the appearance of low values for common physiological parameters during the agonal phase, which may compromise the process by altering graft function. Patients and methods Using the Cochin registry (Paris, France), we conducted a retrospective single-centre study from January 2007 to December 2014. We included all patients who died in ICU after LSTW decision because of post-anoxic brain damages. For each patient, we collected exclusion criteria for DCDMIII and the length of time between LSTW implementation and death. We also collected hemodynamic and respiratory parameters during the agonal phase. Results We included 404 patients in the study, of whom 275 (68%) had at least one exclusion criteria for a DCDMIII process, mostly because of age >65 (190 patients). Other exclusion criteria were: multiple organ failure (n = 88), neoplastic diseases (n = 55, including 46 solid tumours), brain-dead state that occurred after LSTW decision (n = 18), unknown cause of the initial cardiac arrest (n = 13), chronic viral diseases (n = 13), uncontrolled sepsis (n = 4), occurrence of a new refractory cardiac arrest (n = 2), and judicial problems (n = 3).The 130 potentially eligible patients for DCDMIII included 94 men (72%) with a mean age of 51 years (±7.7). At time of death after LSTW, the mean length of stay in ICU was 11.6 days (±6). The most common aetiology of cardiac arrest was acute myocardial ischemia (n = 59, 45%). LSTW consisted in terminal weaning of mechanical ventilation in 71 patients (55%), extubation in 12 patients (9%) and infusion of vasopressors was stopped in 3 patients (2%).The average duration of the agonal phase (time between LSTW implementation and death) was 746 min (min) (±162) and this delay was >180 min in 92 patients (71%). After LSTW implementation, an oxygen transcutaneous saturation (SpO2) <70% occurred in 637 min (±545), a mean arterial pressure (MAP) <60 mmHg in 723 min (±586) and a systolic arterial pressure (SAP) <50 mmHg in 733 min (±596). The delay between SpO2 < 70% and death was 154 min (±262), and this delay was 59 min (±160) after MAP < 60 mmHg and 23 min (±134) after SAP < 50 mmHg. Conclusion In this large cohort of brain damaged patients with LSTW decision, we observed that a high proportion of patients would not have been eligible for a DCDMIIII process. Even in those without contra-indication, the delay between LSTW implementation and the final circulatory arrest was not compatible with French national guidelines. Low values for arterial pressure and oxygenation persisted during a substantial part of time before final circulatory arrest. This information may help in refining the management of the DCDMIII process in this population. Competing interests None.O3 Evaluation of the prognostic value of the bispectral index (BIS) and suppression ratio (RS) among patients admitted to the ICU for cardiac arrestGuylaine Labro1, Francois Belon1, Vinh-Phuc Luu2, Julien Chenet3, Guillaume Besch4, Marc Puyraveau2, Gaël Piton1, Gilles Capellier1 1Réanimation médicale, CHU de Besançon, Besançon, France; 2Centre de méthodologie clinique, CHU de Besançon, Besançon, France; 3Département d'anesthésie et de réanimation, CHU de Besançon, Besançon, France; 4Réanimation chirurgicale, CHU de Besançon, Besançon, France Correspondence: Guylaine Labro - guylainelabro@hotmail.fr Annals of Intensive Care 2017, 7(Suppl 1):O3 Introduction Predicting the neurological outcome of patients admitted to the ICU after a cardiac arrest successfully resuscitated remains difficult [1]. The bispectral index (BIS) allows for the rapid and standardised assessment of the cortical function based upon eletroencephalogram analysis whereas the ratio of suppression (RS) is indicative of the absence of electrical activity of the brain. We aimed to evaluate the prognostic value of the BIS and the RS for predicting neurologic outcome after cardiac arrest. Patients and methods This was a prospective, single center, observational study performed in a large regional University hospital. Adult patients admitted to the ICU for cardiac arrest between March 2012 and October 2014 were included in the study. The exclusion criteria was pregnancy. The BIS and the RS were collected as soon as possible after ICU admission. The patients were not included in the analysis if they died within 24 h, if they had a low signal quality [defined as high EMG artefacts (≥30 dB)], or if the monitoring of BIS started 24 h after ICU admission. The neurological outcome of the patients was based upon the cerebral performans category (CPC) calculated at 3 months. CPC score of 1 or 2 indicated good outcome, whereas CPC score of 3–5 indicated poor outcome. Results During the study period 148 patients were admitted to our ICU for a cardiac arrest. The BIS and RS were monitored in 103 patients.17 patients were excluded (early death ≤24 h; low quality of signal; BIS and RS performed ≥24 h after ICU admission). Thus, 86 patients were enrolled in this study. The means age was 57.6 ± 16.8 years, 61 patients (70.9%) were male, the cardiac arrest was out-of-hospital in 63 patients (73.3%), hypoxia was the main cause of cardiac arrest (43%), 60 patients (70.6%) were treated with therapeutic hypothermia. At 3 month of follow-up, a total of 50 patients (58.1%) had died and 55 patients (63.9%) were classified as having a poor outcome. The mean duration from the return of spontaneous circulation (ROSC) to the BIS and RS measurements was 5.7 ± 3.0 h. The BIS values were significantly lower in patient with poor outcome compared with patients with a good outcome (5.9 ± 11.1 vs 37.1 ± 18.0, p < 0.0001). The RS values were significantly higher in patient with poor outcome group compared to those with good neurological outcome (85.9 ± 26.3 vs 18.4 ± 31.3, p < 0.0001). The BIS predicted poor outcome with a likelihood ratio of 23.8 and an area under the curve (AUC) of 0.918 [95% CI (0.839–0.966)]. The optimal sensitivity [78.4%, 95% CI (67.3–89.5)] and specificity [96.5%, 95% CI (89.8–100)] for neurological outcome prediction was obtained using a cut-off value of BIS < 5. The RS predicted poor outcome with a likehood ratio of 23.8 and an AUC of 0.936 [95% CI (0.862–0.977)]. The optimal sensitivity [78.0%, 95% CI (66.9–89.0)] and specificity [96.8%, 95% CI (90.8–100)] for neurological outcome prediction was obtained using a cut-off value of RS > 84. In multivariable logistic regression model, BIS or RS predicted poor outcome with an odds ratio of 65.0 [95% CI (6.1–689.2), p = 0.0005]. Discussion The results of this study using the EEG derived parameters BIS and RS confirm previous findings showing that they are linked to the neurological outcome of patients admitted to the ICU after a cardiac arrest [2]. In particular, a BIS < 5 and/or a RS > 84, measured at ICU admission, were both strongly associated with a poor neurological outcome at 3-months. Conclusion BIS values may be used to predict long term neurological outcome of patients following cardiopulmonary resuscitation. The ability to accurately predict early non-recovery after cardiac arrest could facilitate discussions with families and limit use of ICU resources in futile cases. BIS and RS values measured at ICU admission might be considered as additional prognostic tools available for the intensivist. Competing interests None. References 1. Sandroni C. Neurological prognostication after cardiac arrest. Curr Opin Crit Care. 2015;21(3):209–14. 2. Seder David B. The bispectral index and suppression ratio are very early predictors of neurological outcome during therapeutic hypothermia after cardiac arrest. Int Care Med. 2010;36:281–88. O4 Nutrition during targeted temperature management after cardiac arrest: observational study of neurological and infectious outcomesMaëlle Martin1, Jean-Baptiste Lascarrou1, Aurélie Le Thuaut2, Jean-Claude Lacherade1, Laurent Martin-Lefèvre1, Maud Fiancette1, Isabelle Vinatier1, Christine Lebert1, Konstantinos Bachoumas1, Aihem Yehia1, Matthieu Henry-Laguarrigue1, Gwenhaël Colin1, Jean Reignier3 1Intensive Care, District Hospital Center, La Roche-sur-Yon, France; 2Clinical Research Unit, District Hospital Center, La Roche-sur-Yon, France; 3Medical Intensive Care Unit, University Hospital Center, Nantes, France Correspondence: Maëlle Martin - maellemart1@gmail.com Annals of Intensive Care 2017, 7(Suppl 1):O4 Introduction Cardiac arrest represents one of the greatest medical challenges because of its terrible mortality, morbidity and cost. International guidelines for cardiopulmonary resuscitation led to survival and prognosis improvement, based on the Chain of Survival and the Advanced Life Support, including Targeted Temperature management (TTM) [1]. Although routinely used, guidelines do not provide detailed management of patients with TTM, especially how to adapt associated therapies such as sedation or nutrition. Guidelines encourage early nutrition for intensive care patients, within 24–48 h after admission [2]. Nevertheless, after cardiac arrest, early nutrition (EN) is disputed. Common post-cardiac arrest syndrome with circulatory failure, frequent diarrheic collapse; and supposed lower digestive tolerance in hypothermia do not encourage this practice.This study first aims to determine if EN is associated with better neurological outcome for patient under TTM. Secondly, we evaluate nutritional tolerance in hypothermia. Patients and methods We retrospectively included patients under TTM after cardiac arrest in a single mixed intensive care unit from January 2008 to December 2014. Patients fed within 48 h after admission (EN; enteral or parenteral) were compared to those fed after 48 h or not fed [delayed nutrition (DN); after rewarming] concerning neurological and infectious outcomes. Enteral nutrition was initiated at maximal caloric objective define at 20 kCal/kg/day until day 7, with isocaloric product. Incidence of vomiting and use of prokinetic drugs were recorded for enteral nutrition tolerance comparison between <36 and ≥36 °C feeding. Results Among 203 patients under TTM at 33 °C after cardiac arrest, 142 were early fed. EN was associated with better neurological outcome assessed by Cerebral Performance Category (CPC) at 3 month (42.3 vs 18%; p = 0.001). After propensity adjustment, EN was still protective for good neurological outcome at 3 month (OR 3.1 [1.36–7.05]; p = 0.01). Comparison between EN and DN showed no difference for early-onset pneumonia (p = 0.4); ventilator-associated pneumonia (VAP) (p = 0.07), nosocomial urinary tract infection (p = 0.35), and nosocomial bacteraemia (p = 0.3). Considering death as competing-risk, VAP were not more frequent with EN (HR 1.07 [0.68–1.69], p = 0.76, Fig. 2). Prokinetic use and vomiting were not increased when nutrition was instituted at temperature <36 °C as compared as ≥36 °C (respectively, 27.2% at 36 °C vs 27.3%, p = 0.99; 34 vs 33%, p = 0.87).Fig. 2Probability of acquering VAP according to early or delayed nutrition groupFull size image Conclusion EN is associated with better neurological outcome during targeted temperature management. EN is not associated with more adverse event (infectious and poor nutrition tolerance) when instituted at temperature less than 36 °C. Competing interests None. References 1. Nolan JP, et al. European Resuscitation Council and European Society of Intensive Care medicine guidelines for post-resuscitation care 2015. Resuscitation. 2015;95:202–22. 2. Taylor BE et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Crit Care Med. 2016;44(2):390–438. O5 Description of the epidemiological characteristics and outcome of cardiac arrest in children: a French studyElodie Privat1, Joséphine Escutnaire2, Cyrielle Dumont3, Valentine Baert2, Christian Vilhelm4, Stéphane Leteurtre5, Hervé Hubert4 1Réanimation pédiatrique, C.H. Régional Universitaire de Lille (CHRU de Lille), Lille, France; 2French National Out-of-Hospital Cardiac Arrest Registry (réac), French National Out-of-Hospital Cardiac Arrest Registry (réac), Lille, France; 3Public Health Department, Université Lille 2 - Faculté de Médecine Henri Warembourg, Loos, France; 4Public Health Department, Université Lille 2 - Faculté de Médecine Henri Warembourg, Lille, France; 5Réanimation pédiatrique, Centre Hospitalier Régional Universitaire de Lille, Lille, France Correspondence: Elodie Privat - elodie.privat@hotmail.fr Annals of Intensive Care 2017, 7(Suppl 1):O5 Introduction Cardiac arrest in children has a very poor prognosis. Knowledge of its epidemiological characteristics is necessary to improve the patient care and survival. The French National Cardiac Arrest registry (RéAC), created in 2009, combines all epidemiological data on out-of-hospital cardiac arrests (OHCA). The objective of this study was to describe the epidemiological characteristics and outcomes of OHCA in children under 18 years old. Materials and methods All patients under 18 years old victims of out-of-hospital cardiac arrest and registered in the French National Cardiac Arrest registry between July 2011 and September 2015 were included. Patients were divided into four groups: infants (under 1 year old), toddlers (1–4 years old), children (5–12 years old) and adolescents (13–17 years old). Variables related to anamnesis, basic cardiopulmonary resuscitation, specialized CPR and outcome of patients were collected. Results Out of 42,960 registered cardiac arrest, 900 (2%) involved children under 18 years of age. Out of the 900 patients enrolled, 393 (44%) were less than 1 year old. The OHCA occurred mainly at home (67%). The percentage of traumatic cardiac arrest increased with age, reaching up to 49% in adolescents. Respiratory failure was the leading cause of cardiac arrest in toddlers and children (respectively 40 and 31%). Adolescents were more likely to have an initial shockable rhythm (8%) than other groups (p < 10−3). The intraosseous access was used in 33% of the children. Overall survival at 1 month was 8.3% (75/900) and 66.7% (50/75) of these patients had a favorable neurological prognosis. Outcomes description per age is described in Table 1.Table 1 Outcome description of patientsFull size table Conclusion There were significant differences between the patient's groups regarding the location, type of cardiac arrest, initial rate, and survival. An age group approach could be considered to improve care strategy and survival of cardiac arrest victims. Competing interests None.O6 Contrast-associated acute kidney injury (AKI) in the intensive care unit (ICU): systematic review and meta-analysisVincent Robert-Edan1, Karim Lakhal1, Andrew Quartin2, Brian Hobbs3, Cynthia Cely2, Cynthia Bell4, Tai Pham5, Roland Schein2, Yimin Geng6, Chaan Ng7, Stephan de chirurgicale, Hôpital Guillaume et CHU de Nantes, Nantes, France; of Critical Care, and of University of of of of University of Center, of of and University of Health of 5Réanimation Hôpital Paris, France; University of Center, of of University of Center, of 8Réanimation de France Correspondence: - Annals of Intensive Care 2017, 7(Suppl Introduction the use of is may to The aim of this systematic review and was to the risk of to in ICU Materials and methods systematic review until December 5 for of following in ICU patients to patients were included in the was performed on data using a mixed multiple logistic regression allows how would assess the risk to according to both a and the of the in the systematic were performed with a An objective a state of a of 1 with a of data collected in the common that the using an a of based on uncontrolled clinical We the a size the a of to a significant a how have to be a that risk to this after with the Results Among compared ICU patients with an group and performed risk for used patient patients were with The a not with no is no that the risk of in the an a of the a of the not when a very high a that a higher than the of the objective and higher than a objective a Conclusion This systematic review and not a risk of to in ICU Competing interests for the between rate and acute kidney injury in patients with acute circulatory Le Isabelle Jean Michel Le Stephan Research in Intensive Care and 1Réanimation de France; médicale, Hôpital CHU France; et de France; 4Réanimation Hôpital de La France; et de France Correspondence: - Annals of Intensive Care 2017, 7(Suppl Introduction kidney injury (AKI) is associated with significant morbidity and mortality, in intensive care unit In patients, rate the index of kidney be the of an such as [1]. There is no to assess in patients, as methods such as of in and urinary have [2]. The aim of this study was to determine using at the initial phase of acute circulatory failure and to evaluate its with of Patients and methods study in 3 French Patients suffering from acute circulatory failure were included within 12 h of ICU admission and a of by of for and 18 and 24 were using high phase and a was to Results patients were included. age was years and 59 patients were admitted for We could in patients to included of the study and early was patients according to the kidney outcome classification In 59 patients of 92 for whom were available in the first 24 h of ICU including patients among the the was related to the of for patients was 40 for 1 patients, 36 for 2 patients and for 3 In 40 of 82 patients the difference between from at the time of and 20 and in most cases For patients, according to was in 18 to patients had by an > 130 patients had according to For the 2 patients with > 130 with both one was was For the patients with according to and not had 1 had a very low and one patients with > 130 according to had a score of 2. Discussion study that of are not a good of We this to be related to the large of infusion at the acute phase following ICU admission and the of nutritional The to may to the of the at the acute phase of as not to be by nutritional factors or Conclusion The between and is very for the of this of assessment in could be used for early of risk and for as is a better of than Competing interests None. References 1. et al. and of acute kidney injury in Crit Care 2. for the of of therapy in patients with acute kidney a analysis of a David Laurent Florence Guillaume Nicolas Nicolas de Julien group de CHU France; et de clinique, Hôpital - France; médicale, Hôpital Henri France; 4Réanimation Centre Hospitalier - de La Roche-sur-Yon, La Roche-sur-Yon, France; et clinique, de Paris Paris, France; 6Réanimation - CHU - France; Hôpital France; 8Réanimation médicale, Centre Hospitalier Universitaire de France; C.H. France; médicale, Centre Hospitalier Universitaire France; médicale, Centre Hospitalier Universitaire France; médicale, CHU France;

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