**Correspondence:** Juliette CHOMMELOUX (juliette.chommeloux@gmail.com)

Annals of Intensive Care 2022, **12**(1):CO-48

**Rationale:** Mortality of COVID- related acute respiratory distress syndrome (ARDS) treated with ECMO did not differ from other ARDS in the first wave of the pandemic. However, ECMO duration and hospital length of stay were much longer. We aimed to assess the long-term quality of life (QoL) and mortality of patients COVID 19 who received ECMO.

**Patients and methods/Materials and methods:** Survivors after ECMO-treated ARDS from March to June 2020 in 7 French Intensive Care Unit (ICU) were followed up at 6 and 12 months after ECMO onset. Pulmonary (CT scan, pulmonary function test, St George score), physical (MRC and examination), and psychological were assessed. QoL was compared to the age-matched French population and patients with non-COVID ARDS treated with ECMO.

**Results:** Eighty out of 132 patients with ECMO were discharged alive during that period. Eighteen patients were lost to follow-up and were not included in our study. The 62 studied survivors were predominantly male, median age 47 [40–55] years, and have very few comorbidities except obesity (BMI 32 [28–36] kg/m2). ECMO and mechanical ventilation duration were 18 [11–25] and 36 [27–62] days, respectively. Besides, their ICU and hospital length of stay were 43 [33–62] and 85 [29–112] days. At 1 year, only one patient was still in the hospital. Pulmonary function tests were good at 6 months except for a persistent impairment of the DLCO. However, 75% of patients had fibrotic-like patterns on the CT scan at that time. QoL, assessed by the SF-36, was impaired compared with the French age-matched population, but also with non-COVID ARDS treated with ECMO. Noticeably, QoL did not improve at 1 year of follow-up. At 1 year, 44% and 42% of the patients had signs of anxiety and depression, respectively, whereas 42% of survivors had symptoms of post-traumatic stress disorder. Lastly, only 38% of these patients returned to their initial work at 1 year.

**Conclusion:** Contrary to non-COVID ARDS, the long-term QoL of COVID patients treated with ECMO was still severely impaired at one year. Besides, a very large proportion of survivors still complained about anxiety, depression, and post-traumatic stress symptoms. These results emphasize the importance to integrate these young patients into customized, patient-centered, rehabilitation programs after ICU discharge.

**Compliance with ethics regulations:** Yes in clinical research.

<figure><img src="image_22.png" /></figure>

Compared quality of life (SF-36) 6 and 12 months after ECMO for severe ARDS due to COVID 19 with non-COVID ARDS on ECMO and French-age matched population

## CO-49

### Late venovenous extracorporeal membrane oxygenation in patients with acute respiratory distress syndrome due to SARS-CoV-2

NATIVEL Mathilde¹, PUECH Bérénice¹, VALANCE Dorothée¹, CALLY Radj¹, DANGERS Laurence¹, JABOT Julien¹, BRAUNBERGER Eric¹, NIGOLEAN Alexandru¹, ALLYN Jérôme¹, ALLOU Nicolas¹, VIDAL Charles¹

¹CHU Nord de La réunion, Saint-Denis, Reunion

**Correspondence:** Mathilde NATIVEL (mathildennativel@gmail.com)

Annals of Intensive Care 2022, **12**(1):CO-49

**Rationale:** Invasive mechanical ventilation (IMV) beyond 10 days is a relative contraindication to venovenous extracorporeal membrane oxygenation (VV-ECMO). Few studies have evaluated the prognosis of late VV-ECMO support in patients with acute respiratory distress syndrome (ARDS) due to SARS-CoV-2. The aim of our study was to evaluate the characteristics and prognosis of patients supported with late VV-ECMO for refractory ARDS due to SARS-CoV-2.

**Patients and methods/Materials and methods:** It was a multicenter, retrospective, observational study that evaluated all patients assisted with VV-ECMO between July 2020 and December 2021 for refractory ARDS related to SARS-CoV-2. We compared the characteristics of patients supported with late VV-ECMO (beyond 10 days of IMV) with those supported with early VV-ECMO (< 10 days).

**Results:** Over the study period, 467 patients were hospitalized in 4 intensive care units (ICU) for SARS-CoV-2 pneumonia. Among them 54 patients with a median age of 51 (42;57) years had required VV-ECMO support (12%). Of the 54 patients, 11 had late VV-ECMO (20%) with a median implantation time of 11 [11–14] days after the beginning of IMV (Table 1). Late implanted patients were less obese (p = 0.02), they tended to have less diabetes mellitus (p = 0.09) and to have a lower simplified acute physiology score (SAPS) II (p = 0.12). At the time of VV-ECMO implantation, significant differences were observed with higher lactatemia in the early implanted group (1.8 mmol/L vs. 1.2 mmol/L, p = 0.02) and higher capnia in the late VV-ECMO patients (67 mmHg vs. 53 mmHg, p < 0.01). Vasopressor support by norepinephrine was comparable between the two groups (p = 0.19). The in-ICU mortality was 56% without significant difference between the two groups (p = 1), even after adjustment for Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score (p = 0.64) or SAPS II (p = 0.99).

**Conclusion:** Late VV-ECMO implantation in patients with refractory ARDS related to SARS-CoV-2 does not appear to be associated with an excess risk of mortality, provided that patients were selected on their clinical characteristics at ICU admission (past medical history, SAPS II) and their severity at the time of implantation (associated organ failures). These results are consistent with other studies concerning SARS-CoV-2 associated ARDS [1,2]. The delay of IMV beyond 10 days should not be a contraindication to the implantation of VV-ECMO in patients with SARS-CoV-2 associated ARDS.

**Reference 1:** Olivier et al. Crit Care (2021) Prolonged time from intubation to cannulation in VV-ECMO for COVID-19: does it really matter? 25:385 https://doi.org/10.1186/s13054-021-03800-5.

**Reference 2:** Hermann et al. Annals of Intensive Care (2022) Duration of invasive mechanical ventilation prior to extracorporeal membrane oxygenation... 12:6 https://doi.org/10.1186/s13613-022-00980-3.

**Compliance with ethics regulations:** Yes in clinical research.
<table><caption>Table 1: Selected characteristics at implantation of the whole population and univariate analyses between early (<10 days of mechanical ventilation) and late (beyond 10 days) VV-ECMO. Results are expressed as median ([Q25; 75] or number (%).</caption><thead><tr><th>Characteristics at<br>implantation</th><th>All patients<br>n = 54</th><th>Early ECMO<br>n = 43</th><th>Late ECMO<br>n = 11</th><th>p</th></tr></thead><tbody><tr><td>Age (years)</td><td>51 (42.5; 57)</td><td>50 (43; 56)</td><td>52 (44.5; 57.5)</td><td>0.86</td></tr><tr><td>Male</td><td>37 (69%)</td><td>27 (63%)</td><td>10 (91%)</td><td>0.14</td></tr><tr><td>BMI (kg/m²)</td><td>28.2 (25.5; 33)</td><td>29 (25.9; 34)</td><td>25.7 (24.5; 27)</td><td>0.034</td></tr><tr><td>Obesity<br>(BMI (≥ 30 kg/m²))</td><td>22 (41%)</td><td>21 (49%)</td><td>1 (9%)</td><td>0.019</td></tr><tr><td>Diabetes mellitus</td><td>23 (43%)</td><td>21 (49%)</td><td>2 (18%)</td><td>0.092</td></tr><tr><td>High blood pressure</td><td>18 (33%)</td><td>16 (37%)</td><td>2 (18%)</td><td>0.3</td></tr><tr><td>Invasive mechanical<br>ventilation</td><td>4 (2; 8)</td><td>3 (1; 4.5)</td><td>11 (10.5; 13.5)</td><td>&lt;0.001</td></tr><tr><td>RESP score</td><td>2.5 (2; 4)</td><td>4 (2; 5)</td><td>2 (0; 2)</td><td>0.011</td></tr><tr><td>SAPS II</td><td>34 (25; 44)</td><td>37 (25; 46)</td><td>27 (24; 31)</td><td>0.12</td></tr><tr><td>Lactatemia (mmol/L)</td><td>1.6 (1.3; 2.6)</td><td>1.8 (1.3; 3.2)</td><td>1.2 (1; 1.6)</td><td>0.018</td></tr><tr><td>Creatinine levels (μmol/L)</td><td>67 (53; 96)</td><td>68 (53; 99)</td><td>73 (57; 189)</td><td>0.53</td></tr><tr><td>PaO2/FiO2</td><td>61 (55; 76)</td><td>61 (55; 74)</td><td>74 (58; 82)</td><td>0.16</td></tr><tr><td>PaCO2 (mmHg)</td><td>56 (45; 66)</td><td>53 (44; 60)</td><td>67 (59; 75)</td><td>&lt;0.01</td></tr><tr><td>NAD</td><td>30 (56%)</td><td>26 (60%)</td><td>4 (36%)</td><td>0.19</td></tr><tr><td>In-ICU mortality</td><td>30 (56%)</td><td>24 (56%)</td><td>6 (55%)</td><td>1</td></tr><tr><td>Hospital length of stay (days)</td><td>44.5 (29; 67)</td><td>44 (29; 69)</td><td>58 (33; 65)</td><td>0.74</td></tr></tbody></table>

CO-50

DD ECMO: Prevalence and evolution of diaphragmatic dysfunction in patients with acute respiratory distress syndrome under veno-venous ECMO

GAUTIER Melchior¹, JOUSSELIN Vincent¹, DEMOULE Alexandre¹, COMBES Alain¹, SCHMIDT Matthieu¹, DRES Martin¹

¹Pitié Salpetrière, Paris, France

**Correspondence:** Melchior GAUTIER (melchiorgautier25@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-50

**Rationale:** ECMO is currently part of care in severe acute respiratory distress syndrome (ARDS). Its use is frequently associated with prolonged deep sedation and neuromuscular blockades, that may lead to diaphragm dysfunction. This latter is associated with delayed mechanical ventilation weaning and poor outcomes. Our study aims to assess the prevalence of diaphragmatic dysfunction in a large population of severe ARDS on veno-venous ECMO. We hypothesize that diaphragmatic dysfunction is frequent, severe, and associated with prolonged mechanical ventilation and poor outcomes in that severe population.

**Patients and methods/Materials and methods:** We conducted a prospective, observational study in two medical intensive care units. All patients with SARS-CoV-2 related ARDS requiring veno-venous ECMO were included from February 1 to September 31, 2021. Diaphragmatic function was daily assessed by measuring diaphragm pressure generation in response to phrenic nerve stimulation (Ptr,stim) from ECMO initiation until ECMO weaning.

**Results:** Sixty-three patients were included with a median age of 53 (42–59) years old and after a median of 4 days (2–6) of mechanical ventilation. Diaphragmatic dysfunction upon inclusion (at day 1 of ECMO) was present in 38 patients (60%). Patients with diaphragmatic dysfunction at day 1 were older (55 years [43–60] vs. 48 years [40–55], p = 0.042) and had a higher LUS (Lung Ultrasound score as a surrogate of lung aeration loss) (26 vs. 24, p = 0.037). Diaphragmatic function did not significantly change over the study period (Fig. 1). 24 patients had a successful ECMO weaning, sixteen patients (67%) had diaphragmatic dysfunction the day of ECMO weaning. Besides, these patients had longer mechanical ventilation duration when compared to those without diaphragmatic dysfunction (62.9 vs 41.7 days).

**Conclusion:** Diaphragmatic dysfunction is frequent in ARDS patients undergoing ECMO for SARS-CoV-2 infection. When present at ECMO

day-1, diaphragmatic dysfunction did not seem to evolve over time. However, it was associated with a longer duration of mechanical ventilation in patients successfully weaned from ECMO.

**Compliance with ethics regulations:** Yes in clinical research.

<figure><img src="image_23.png" /><figcaption>Figure 1: Time course of diaphragmatic function from D1 to ECMO weaning. Values are presented as medians with their standard deviations. The red line corresponds to the threshold of 11 cmH₂O below which diaphragmatic dysfunction is defined.</figcaption></figure>

CO-51

Impaired pharmacokinetics of amiodarone under veno-venous extracorporeal membrane oxygenation: from bench to bedside

LESCROART Mickael¹, PRESSIAT Claire², PEQUIGNOT Benjamin¹, HÉBERT Jean-Louis³, ALSAGHEER Nassib¹, SCALA BERTOLA Julien¹, LEVY Bruno¹

¹CHRU Nancy, Vandoeuvre, France; ²CHRU Henri Mondor, Créteil, France;

³Hopital Pitié Salpetrière, Institut de cardiologie, Paris, France

**Correspondence:** Mickael LESCROART (dr.lescroart@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-51

**Rationale:** Adjusting drug therapy under Veno-Venous Extra-Corporeal-Membrane-Oxygenation (VV-ECMO) is challenging. Albeit impaired pharmacokinetics (PK) under VV-ECMO have been reported for sedative drugs and antibiotics, data about amiodarone are lacking. We assessed the PK of amiodarone under VV-ECMO in vitro and in vivo using a porcine model of cardiac arrest ongoing CPR previously injured with ARDS rescued by VV-ECMO.

**Patients and methods/Materials and methods:** In vitro: closed loop ECMO were used for studying amiodarone adsorption over a 120 min period versus a recipient control. Amiodarone bolus (100 and 300 mg) were studied. In vivo: ARDS was induced in 10 pigs. Animals were randomly assigned to control or VV-ECMO groups. Amiodarone 300 mg was injected once CPR started and twelve blood samples were drawn over a 12 min period. Pharmacokinetic analysis was performed with non-linear mixed effects modelling.

**Results:** In vitro study revealed a significant decrease in amiodarone concentrations after 10 min and a loss of 99.6% of amiodarone concentrations after 120 min. In vivo pharmacokinetics revealed a significant decrease of Cmax, with 123.5 mg/L (109.5–150.0) versus 61.7 mg/L (55.3–80.3) in the control vs ECMO groups (p = 0.02), respectively without delaying time to peak concentration with 90 s (60–90) versus 90 s (75–90), respectively (p = 1). VV-ECMO significantly modified central distribution volume and amiodarone clearance. Monte-Carlo simulations predicted that amiodarone 600 mg bolus under VV-ECMO could achieve the AUC observed in the control group.

**Conclusion:** This is the first study reporting pharmacokinetics of amiodarone under VV-ECMO in an animal model. We found significant alterations of drug delivery. Higher amiodarone doses might be considered for efficient pharmacokinetics under VV-ECMO.

**Compliance with ethics regulations:** Yes in animal testing.
<figure><img src="image_24.png" /></figure>

Panel A: experimental protocol. Panel B: Visual Predictive Check for amiodarone model. Left panel: control group. right panel: ECMO group. Panel C: Monte Carlo simulations to reach amiodarone AUC Q1–Q3 in the control group.

CO-52

Increasing sweep gas flow through the membrane lung reduces dyspnea and respiratory drive in veno-arterial ECMO patients– The DysCO 2 study

BUREAU Côme<fnref n="1" />, SCHMIDT Matthieu<fnref n="1" />, NIERAT Marie-Cécile<fnref n="1" />, DANGERS Laurence<fnref n="1" />, CLERC Sébastien<fnref n="1" />, JOUSSELLIN Vincent<fnref n="1" />, MAYAUX Julien<fnref n="1" />, MORAWIEC Elise<fnref n="1" />, COMBES Alain<fnref n="1" />, SIMILOWSKI Thomas<fnref n="1" />, DEMOULE Alexandre<fnref n="1" />

Correspondence: Côme BUREAU (come.bureau@aphp.fr)

Annals of Intensive Care 2022, 12(1):CO-52

**Rationale:** Patients with severe heart failure may benefit from veno-arterial extracorporeal membrane oxygenation vaECMO, which preserves systemic blood flow. In addition, the vaECMO oxygenation membrane ensures blood oxygenation and CO₂ removal. In clinical practice, vaECMO patients may exhibit dyspnea despite adequate blood flow and the absence of blood gas abnormalities. Our objective was to evaluate, in vaECMO patients exhibiting significant dyspnea, the impact of an increase in sweep gas flow through the vaECMO membrane on dyspnea.

**Patients and methods/Materials and methods:** Patients with (1) vaECMO for cardiogenic shock and (2) a dyspnea ≥ 40 mm on a visual analog dyspnea scale (Dyspnea-VAS) from zero to 100 mm were included. Four conditions were studied: on inclusion and after three sweep gas flow increments of two liters per minute each. Dyspnea was assessed with the Dyspnea-VAS, the A1 score of the Multidimensional Dyspnea Profile and the Intensive Care Respiratory Distress Operating Scale (IC-RDOS). The respiratory drive was concomitantly assessed by the measure of the electromyographic activity of the Alea Nasi and parasternal muscles.

**Results:** We included 21 non-mechanically ventilated patients. Median (interquartile range) age was 40 years (30–55), 62% male and duration of ECMO was 3 days (2–4). Dyspnea-VAS was 50 (45–60) mm. Weinberg radiological pulmonary oedema score was 3 (0–5). Gas flow at inclusion was 1 L/min (0.5–2). Table 1 shows respiratory rate, PaCO₂, Dyspnea-VAS, A1 score and IC-RDOS across the four conditions. PaCO₂ decreased in response to the 2-L-per-minute increase in sweep, but it ceased to decrease after 6 L. Dyspnea did not decrease immediately

but was significantly lower after 6 L of increased sweep regardless of the assessment score. The electromyographic activity of Alea nasi and parasternal muscles decreased significantly after sweep gas flow increment. There was a significant inverse correlation between the Dyspnea-VAS and the sweep gas flow (Rho = -0.68, p < 0.0001) but not between Dyspnea-VAS and PaCO₂ (Rho = 0.136, p = 0.236).

**Conclusion:** In critically ill patients with vaECMO, incrementation of sweep gas flow through the oxygenation membrane decreases dyspnea. It might be mediated by a decrease in respiratory drive, as suggests the concomitant decrease in respiratory rate and electromyographic activity of respiratory muscles.

**Compliance with ethics regulations:** Yes in clinical research.

<table><thead><tr><th></th><th>Baseline</th><th>+2 L/min</th><th>+4 L/min</th><th>+6 L/min</th><th>p</th></tr></thead><tbody><tr><td>Sweep gas flow</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Sweep gas, L/min<sup>-1</sup></td><td>1 (0.5-2)</td><td>3 (2.5-4)</td><td>5 (4.5-6) * $</td><td>7 (6.5-8) * $</td><td>&lt;0.0001</td></tr><tr><td>Clinical parameters</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>RR, min<sup>-1</sup></td><td>23 (21-25)</td><td>21 (18-22)</td><td>19 (16-20) *</td><td>15 (13-17) * $</td><td>&lt;0.0001</td></tr><tr><td>Blood gases</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>PaCO<sub>2</sub>, mmHg</td><td>37 (31-40)</td><td>33 (28-38)</td><td>32 (29-37) *</td><td>34 (31-39)</td><td>0.004</td></tr><tr><td>Dyspnea</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Sensory D-VAS, mm</td><td>50 (45-60)</td><td>50 (40-50)</td><td>40 (30-40) * $</td><td>20 (10-30) * $</td><td>&lt;0.0001</td></tr><tr><td>A1</td><td>50 (50-60)</td><td>50 (50-60)</td><td>50 (40-60)</td><td>40 (30-50) * $</td><td>&lt;0.0001</td></tr><tr><td>IC-RDOS</td><td>5.0 (3.8-6.6)</td><td>4.8 (3.0-5.8)</td><td>3.3 (2.7-5.1)</td><td>2.9 (2.7-4.6) *</td><td>&lt;0.0001</td></tr><tr><td>Electromyography</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Alea Nasi EMGmax</td><td>1 (1-1)</td><td>0.94 (0.67-0.99)</td><td>0.86 (0.63-0.99) *</td><td>0.78 (0.50-0.99) *</td><td>0.0002</td></tr><tr><td>Parasternal EMGmax</td><td>1 (1-1)</td><td>0.99 (0.93-1.00)</td><td>0.94 (0.87-0.99) *</td><td>0.87 (0.75-0.98) * $</td><td>0.0001</td></tr></tbody></table>

p < 0.05 compared to the Baseline condition, $ p < 0.05 compared to the +2 condition, £ p < 0.05 compared to the +4 condition

CO-53

Amniotic fluid embolism rescued by venoarterial extracorporeal membrane oxygenation

AISSI JAMES Sarah <fnref n="1" />, KLEIN Thomas², LEBRETON Guillaume <fnref n="1" />, NIZARD Jacky<fnref n="1" />, CHOMMELOUX Juliette<fnref n="1" />, BRECHOT Nicolas<fnref n="1" />, PINETON DE CHAMBRUN Marc<fnref n="1" />, HEKIMIAN Guillaume<fnref n="1" />, LUYT Charles-Edouard<fnref n="1" />, LEVY Bruno², KIMMOUN Antoine², COMBES Alain<fnref n="1" />, SCHMIDT Matthieu<fnref n="1" />

¹Hôpital Pitié Salpêtrière, Paris, France; ²CHRU, Nancy, France **Correspondence:** Sarah AISSI JAMES (sarah.aissi@live.fr)

Annals of Intensive Care 2022, 12(1):CO-53

**Rationale:** Amniotic fluid embolism (AFE) is a rare but often catastrophic complication of pregnancy. The cardiopulmonary dysfunction associated with AFE being typically self-limited, venoarterial extracorporeal membrane oxygenation (VA-ECMO) support has been reported in the most severe forms. Data available on AFE rescued by VA-ECMO were mainly described in single-case reports and concern can be raised about the bleeding risks with ECMO in that context. The objectives of this retrospective study were to report outcomes of ECMO-treated AFE; to describe their critical care management and in-ICU complications; and to report long-term maternal health-related quality of life (HRQOL).

**Patients and methods/Materials and methods:** This study included patients with AFE, according to Clark diagnostic criteria (1), rescued by VA-ECMO and hospitalized in two ECMO centers between August 2008 and February 2021. Clinical characteristics, peri-delivery resuscitative procedures and critical care management are detailed. Main outcome variables included survival to ICU discharge, days under ECMO therapy, ECMO-associated complications, time on mechanical ventilation, ICU length of stay. ICU survivors were assessed for long term HRQOL during a phone interview in May 2021 by completing the Short-Form 36 questionnaire and the Impact of Event Scale screening for Post-Traumatic Stress Disorder (PTSD)-related symptoms.

<footnote n="1">¹Hôpital Universitaire Pitié-Salpêtrière, Paris, France</footnote>
**Results:** During that 13-year study period, 10 patients with AFE were treated with VA-ECMO. Seven patients had a cardiac arrest before ECMO and two were cannulated under cardiopulmonary resuscitation. Pre-ECMO hemodynamic was severely impaired with an inotrope score at 370 (55-1530) µg/kg/min, a severe left ventricular ejection fraction at 14 (0-40) %, lactate at 12 (2-30) mmol/L, SAPS II at 69 (56-81) and massive blood transfusion requirement. 70% of these patients were alive at hospital discharge, 50% reported ECMO-related complications. Median durations of ECMO and mechanical ventilation support were respectively 4 (1-6) and 5 (1-13) days. The median ICU length of stay was 12 (1-25) days. All infants survived. HRQOL was lower than age-matched controls and still profoundly impaired in the role-physical, bodily pain, and general health components after a median of 44 months follow-up (Fig. 1). Four out of seven patients returned to their initial work.

**Conclusion:** In this rare per-delivery complication, our results support the use of VA-ECMO despite extreme initial severity, intense disseminated intravascular coagulation and ongoing bleeding. However, long-term physical and mental status were still impaired after long-term evaluation. Future studies should therefore focus on customized, patient-centered, rehabilitation programs to improve HRQOL.

**Reference 1:** Clark SL, Romero R, Dildy GA, Callaghan WM, Smiley RM, Bracey AW, et al. Proposed diagnostic criteria for the case definition of amniotic fluid embolism in research studies. Am J Obstet Gynecol. 2016;215:408-12.

**Compliance with ethics regulations:** Yes in clinical research.

<caption>**Figure 2:** Comparison of mean SF-36 scores of AFE survivors treated by ECMO after a median follow-up of 40 months after intensive care unit discharge and their age- and sex-matched French control subjects [10], and 84 venovenous ECMO treated ARDS survivors [12], and 32 severe septic shock rescued by VA-ECMO [13].</caption>

Higher scores denote a better health-related quality of life.

<figure><img src="image_25.png" /></figure>

ARDS, acute respiratory distress syndrome; VV-ECMO, venovenous extracorporeal membrane oxygenation; VA-ECMO, venoarterial extracorporeal membrane oxygenation

Comparison of SF-36 scores of AFE survivors treated by ECMO after a median follow-up of 40 months after ICU discharge and their age- and sex-matched control subjects, 84 venovenous ECMO-treated ARDS survivors, and 32 septic shock rescued by VA-ECMO

CO-54

**Extracorporeal life support allows lung transplant in anti-MDA5+ rapidly progressive-interstitial lung disease**

BAY Pierre¹, PINETON DE CHAMBRUN Marc², ROUX Antoine⁴, BUNEL Vincent⁶, COMBES Alain², ISRAËL BIET Dominique⁵, ZUBER Benjamin⁴, NUNES Hilario³, ALLENBACH Yves², UZUNHAN Yurdagul³

¹Hopital Henri Mondor, Creteil, France; ²Hopital Pitié Salpétrière, Paris, France; ³Hopital Avicenne, Paris, France; ⁴Hopital Foch, Suresnes, France;

⁵Hopital Européen Georges Pompidou, Paris, France; ⁶Hopital Bichat, Paris, France

**Correspondence:** Pierre BAY (pierrebay53@yahoo.fr)

Annals of Intensive Care 2022, **12**(1):CO-54

**Rationale:** Anti-melanoma differentiation-associated gene 5 antibody (anti-MDA5) dermatomyositis (DM) is a rare subtype of idiopathic inflammatory myopathy, associated with severe interstitial lung disease (ILD). A subset of anti-MDA5 DM patients with rapidly progressive ILD (RP-ILD) have a very poor prognosis with reported mortality rates reaching 80-84%. The use of extracorporeal life support (ECLS) is questionable, as reported in several studies that emphasize the futility of a bridge-to-recovery strategy. In this respect, emergency lung transplantation of previously unlisted patients on ECLS is under debate.

**Patients and methods/Materials and methods:** This French, multicenter, retrospective study, conducted from 2013 to 2021 included all patients with anti-MDA5 DM RP-ILD requiring ECLS.

**Results:** Fifteen patients requiring ECLS were included in the study: venovenous -ECMO n=13, ECCO2R n=1 and venoarterial-ECMO n=1. The female-to-male ratio was 4 and the age at ICU admission was a mean of 50 [32-67] years. Two patients received ECLS support (1 ECMO VA, 1 ECMO VV) as a bridge-to-transplantation strategy and both underwent ECLS before mechanical ventilation. Five patients underwent lung transplantation after a median of 8 [4-20] days on ECMO, none previously listed for a lung transplantation. After a median follow-up of 25 [3-93] months, all transplanted patients were alive at the conclusion of the study (four discharged home, one still hospitalized) and no relapse of DM or ILD was noted. All other patients, not listed for lung transplantation, died after a median of 30 [4-52] days on ECMO (Fig. 1).

**Discussion:** The prognosis of anti-MDA5 RP-ILD seems inevitably poor despite aggressive immunosuppression and the use of ECLS. The results presented here provide crucial information for the management of anti-MDA5 RP-ILD. First, we highlight the refractory nature of the anti-MDA5 RP-ILD requiring ECLS. No anti-MDA5 RP-ILD patient, irrespective of the treatment regimen they receive, including the most recent biologics such as JAK inhibitors, should be weaned from the ECLS. Second, every patient that could be bridge-to-transplantation was discharged alive from ICU. None was previously listed for lung transplantation. Emergency lung transplantation was possible in patients treated with vasopressors, mechanical ventilation and ECLS.

**Conclusion:** The bridge-to-recovery strategy in anti-MDA5 RP-ILD patients requiring ECLS despite specific prior treatment leads to undesirable results, pointing to the drawbacks of this approach. In contrast, a bridge-to-emergency lung transplantation is not only feasible, but also associated with a favorable outcome and appears therefore as the sole hope of survival for patients requiring ECLS.

**Reference 1:** Vuillard C, Pineton de Chambrun M, de Prost N, Guérin C, Schmidt M, Dargent A, et al. Clinical features and outcome of patients with acute respiratory failure revealing anti-synthetase or anti-MDA-5 dermato-pulmonary syndrome: a French multicenter retrospective.
**Reference 2:** Rubin J, Black KE, Hallowell RW, Witkin AS, Lydston M, Shelton K, et al. Veno-Venous Extracorporeal Membrane Oxygenation (ECMO) for Myositis-Associated Rapidly Progressive Interstitial Lung Disease (RP-ILD). CHEST [Internet]. 2021 Jul 16 [cited 2021 Jul 1].

**Compliance with ethics regulations:** Yes in clinical research.

<figure><img src="image_26.png" /></figure>

Kaplan-Meier 120-days Survival Estimates according to lung transplantation status

## CO-55

### Trends in clinical characteristics and outcomes of Covid-19 critically ill adult patients in France: a national database study

NAOURI Diane⁶, BEDUNEAU Gaetan⁴, DRES Martin², KIMMOUN Antoine⁵, COMBES Alain², DEMOULE Alexandre⁶, MERCAT Alain³, PHAM Tai², SCHMIDT Matthieu², JAMME Matthieu¹

¹Hopital privé de l'ouest parisien, Trappes, France; ²Assistance publique hopitaux de Paris, Paris, France; ³CHU Angers, Angers, France; ⁴CHU Rouen, Rouen, France; ⁵CHU Nancy, Nancy, France; ⁶Direction de la recherche, des études, de l'évaluation et des statistiques (DREES), Paris, France

**Correspondence:** Matthieu JAMME (mat.jamme@gmail.com)

*Annals of Intensive Care* 2022, **12**(1):CO-55

**Rationale:** Data concerning the association between time-period of ICU hospitalization and prognosis of patients admitted for coronavirus disease 2019 (COVID-19) are scarce. We aimed to describe the characteristics and the outcomes over time of critically ill patients cared in ICU for COVID-19.

**Patients and methods/Materials and methods:** We conducted a retrospective cohort study using the French administrative health care database (Système National des Données de Santé, SNDS). All adult patient hospitalized in French ICUs from March 1, 2020, to June 30, 2021 with at least one ICD-10 diagnosis code of COVID-19 was included. Three time-period corresponding to surge of COVID-19 ICU admission were defined: the first one between March 1, and June 30, 2020; the second between July 1, and December 31, 2020; and the third from January 1, to June 30, 2021. Risk factors of mortality and invasive mechanical ventilation (iMV) were identified by multivariate logistic regression models.

**Results:** 105979 COVID-19 patients were admitted in ICU during the study period with respectively 25150, 32689, and 48140 patients during the first, second, and third surge. First surge was remarkable with the highest proportion of iMV (42%, 32% and 31% for respectively surge 1, 2 and 3; p < 0.001), of renal replacement therapy (RRT) (9%, 7% and 5% for respectively surge 1, 2 and 3; p < 0.001) and use of vasopressors (36%, 26% and 24% for respectively surge 1, 2 and 3; p < 0.001). Second wave was composed with older patients (respectively 50% of more than 70 years vs 41% for wave 1 and 3) and higher IGS-2 score at ICU admission (33 [26–42]). Multivariate model identified age, male

gender, Charlson score, IGS 2 score and ICU admission after the first wave as risk factors of in-hospital death. After stratification on age, the odds ratios of in-hospital death were higher only in patients older than 70 years for the third wave (aOR = 1.30; 95% CI = 1.23–1.37) and the second wave (aOR = 1.15; 95% CI = 1.08–1.22), compared to those younger than 69 years old. During the third wave, 4971 (9%) patients had been vaccinated at ICU admission. Vaccination was associated with a lower likelihood of invasive mechanical ventilation (OR = 0.50, 95% CI = 0.40–0.63) and death (OR = 0.74, 95% CI = 0.60–0.90).

**Conclusion:** Between March 2020 and July 2021, we reported a decline in iMV, vasopressors and RRT use for ICU patients admitted for COVID-19. Second and third wave were associated with in-hospital mortality for patients with 70 years and more. Finally, vaccination was associated with a lower likelihood of iMV and death.

**Compliance with ethics regulations:** Yes in clinical research.

## CO-56

### Comparison of SARS-CoV-2 variants of concern Alpha (B.1.1.7) versus Beta (B.1.351) in critically ill patients: a multicenter cohort study in the northeast of France

LOUIS Guillaume¹, BELVEYRE Thibaut², GIBOT Sebastien³, GOETZ Christophe⁵, DUNAND Paul⁶, GACI Rostane¹, CONRAD Marie³, CADOZ Cyril¹, GETTE Sebastien¹,⁴, PEREZ Pascale⁶, OUAMARA Nadia⁵, PICARD Yoann¹, MELLATI Nouchan¹

¹Intensive Care Unit, Metz-Thionville Regional Hospital, Mercy Hospital, Metz, France, Metz, France; ²Department of Anesthesiology and Intensive Care Medicine, University Hospital of Nancy, Vandoeuvre-Lès-Nancy, France, Vandoeuvre-Les-Nancy, France; ³Medical Intensive Care Unit, University Hospital of Nancy, Nancy, France, Nancy, France; ⁴Intensive Care Unit, Metz-Thionville Regional Hospital, Bel Air Hospital, Thionville, France, Thionville, France; ⁵Clinical research support Unit, Metz-Thionville Regional Hospital, Mercy Hospital, Metz, France, Metz, France; ⁶Department of Virology, Metz-Thionville Regional Hospital, Mercy Hospital, Metz, France, Metz, France

**Correspondence:** Guillaume LOUIS (gus_louis@yahoo.fr)

*Annals of Intensive Care* 2022, **12**(1):CO-56

**Rationale:** The clinical outcomes of the Beta (B.1.351) variant of concern (VOC) of the SARS-CoV-2 virus remain poorly understood. In early 2021, northeastern France experienced an outbreak of Beta that was not observed elsewhere. This outbreak slightly preceded and then overlapped with a second outbreak of the better understood VOC Alpha (B.1.1.7) in the region. This situation allowed us to contemporaneously compare Alpha and Beta in terms of the characteristics, management, and outcomes of critically ill patients.

**Patients and methods/Materials and methods:** A multicenter cohort study was conducted on all consecutive adult patients who had laboratory confirmed SARS CoV-2 infection, underwent variant screening, and were admitted to one of four intensive care units for acute respiratory failure between January 9th and May 15th 2021. Primary outcome was 60-day mortality. Differences between Alpha and Beta in terms of other outcomes, patient variables, management, and vaccination characteristics were also explored by univariate analysis. The factors that associated with 60-day death in Alpha- and Beta-infected patients were examined with logistic regression analysis.

**Results:** In total, 333 patients (median age, 63 years) were enrolled. Of these, 174 and 159 had Alpha and Beta, respectively. The two groups did not differ significantly in terms of 60-day mortality (19% vs. 23%), need for mechanical ventilation (60% vs. 61%), mechanical ventilation duration (14 vs. 15 days), other management variables, patient demographic variables, comorbidities, or clinical variables on ICU admission. The vast majority of patients were unvaccinated (94%). The remaining 18 patients had received a partial vaccine course and 2 were fully vaccinated. The vaccinated patients were equally likely to have Alpha and Beta.

**Discussion:** To date, this is one of the largest studies to compare the characteristics and outcomes of critically ill patients who were infected with either of two simultaneously circulating VOCs and who underwent similar treatment regimens in the same settings. A
Universitaires Henri Mondor, Créteil, France; ¹¹Service de Médecine Intensive-Réanimation, AP-HP, Hôpital de Bicêtre, DMU 4 CORREVE Maladies du Cœur et des Vaisseaux, FHU Sepsis, Groupe de Recherche Clinique CARMAS, Le Kremlin-Bicêtre, France; ¹²Service de Médecine Intensive-Réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP). Centre & Université de Paris, Paris, France; ¹³Médecine Intensive Réanimation, AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Colombes, France; ¹⁴Service de médecine intensive et réanimation, Hôpital Saint-Louis, Assistance Publique Des Hôpitaux de Paris, Paris, France; ¹⁵Département de réanimation médico-chirurgicale, APHP Hôpital Avicenne, Bobigny, France; ¹⁶Groupe Hospitalier Pitié Salpetrière, Assistance Publique Hôpitaux de Paris, Service de Pneumologie et Réanimation Médicale, Paris, France; ¹⁷Unité de Recherche Clinique AP-HP, Hôpitaux Henri-Mondor, Créteil, France; ¹⁸Service de Médecine intensive Réanimation, APHP.Sorbonne Université, Hôpital Pitie Salpetrière, Paris, France

**Correspondence:** Romain ARRESTIER (romain.arrestier@aphp.fr)

Annals of Intensive Care 2022, 12(1):CO-58

**Rationale:** SARS-CoV-2 infection leads to a broad spectrum of symptoms with a large inter-individual variability. Impaired interferon (IFN) type I response seems to be involved in patients with severe SARS-CoV-2 infection. Auto-antibodies (auto-Abs) neutralizing type I IFN-α2 and IFN-ω were found in 10% of severe COVID-19 cases compared with 0% in mildly or asymptomatic cases. Dertermining whether auto-Abs neutralizing type I IFNs are associated with outcomes in critically ill patients with COVID-19 could lead to individualized therapeutic interventions.

**Patients and methods/Materials and methods:** We conducted a prospective multicentre study including 11 intensive care units (ICU). Patients hospitalized in ICU with proven SARS-CoV-2 infection and acute respiratory failure requiring oxygen or mechanical ventilation support were included. Our objectives were to compare the mortality of patients with versus without auto-Abs neutralizing type I IFNs, to assess the rate of positivity of auto-Abs and the factors associated with their positivity.

**Results:** 925 critically ill COVID-19 patients were included in the study between March 2020 and May 2021. Auto-Abs neutralizing type I IFN were found in 96 patients (10.3%): 78.3% had auto-Abs against IFN-α2, 74% against IFN-ω and 12.5% against IFN-β. Baseline characteristics did not differ between patients with and without auto-Abs (Table 1). At ICU admission, positive patients required a higher FiO₂ (100% (70–100) vs 90% (60–100), p = 0.01), and more frequently met the diagnosis criteria for the acute respiratory distress syndrome (92.7% vs 77.6%, p = 0.0005). Mortality at day 28 was not different between groups (18.7% vs 23.7%, p = 0.279). In multivariable analysis, age (adjusted odds ratio (aOR) = 1.06 [1.04–1.08], p < 0.001), SOFA score (aOR = 1.18 [1.12–1.23], p < 0.001) and immunosuppression (aOR = 1.82 [1.1–3.0], p = 0.02) were associated with 28-days mortality, but auto-Abs positivity was not (aOR = 0.69 [0.38–1.26], p = 0.23). There was a non-significant trend towards a higher proportion of men among positive patients (78 vs 70%) contrasting with the previous finding that auto-Abs were almost uniquely detected in men (94%)¹. Compared to women without auto-Abs, positive women were significantly younger (45 (24–62) vs 60 years (45.5–67.5)) and more frequently displayed an auto-immune background with more frequent positive anti-nuclear antibody (28% vs 4%, p = 0.003). They required more frequent invasive mechanical ventilation (71% vs 47%, p = 0.04) at ICU admission but 28-days mortality was not different.

**Conclusion:** In ICU patients, auto-Abs against type I IFNs are present in 10% of patients but are not associated with higher 28 days mortality. Positive women seem to have an auto-immune background and more frequently required mechanical ventilation.

**Reference 1:** Bastard, P. et al. Autoantibodies against type I IFNs in patients with life-threatening COVID-19. Science 370, eabd4585 (2020).

**Compliance with ethics regulations:** Yes in clinical research.

<table><caption>**Table 1.** Demographics and characteristics of patients with severe SARS-CoV-2 infection (n=925) at intensive care unit admission and ICU management and outcomes according to the presence of antibodies against type I IFNs</caption><thead><tr><th></th><th>Total<br>N=925</th><th>Negative anti IFN<br>Abs<br>N=829</th><th>Positive anti IFN Abs<br>N=96</th><th>p-value*</th></tr></thead><tbody><tr><td><strong>Comorbidities</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Age</td><td>62 (53.69,7)</td><td>62.0 (53.69,5)</td><td>63.8 (53.9,70.5)</td><td>0.668</td></tr><tr><td>Gender</td><td></td><td></td><td></td><td>0.083</td></tr><tr><td>Male</td><td>652 (70.5%)</td><td>577 (69.6%)</td><td>75 (78.1%)</td><td></td></tr><tr><td>Female</td><td>273 (29.5%)</td><td>252 (30.4%)</td><td>21 (21.9%)</td><td></td></tr><tr><td>Obesity (N=861)</td><td>370 (43%)</td><td>335 (43.4%)</td><td>35 (39.3%)</td><td>0.463</td></tr><tr><td>Congestive heart failure</td><td>94 (10.2%)</td><td>85 (10.3%)</td><td>9 (9.4%)</td><td>0.787</td></tr><tr><td>Vasculopathy</td><td>101 (10.9%)</td><td>87 (10.5%)</td><td>14 (14.6%)</td><td>0.224</td></tr><tr><td>Hypertension</td><td>474 (51.2%)</td><td>429 (51.8%)</td><td>45 (46.9%)</td><td>0.366</td></tr><tr><td>COPD</td><td>62 (6.7%)</td><td>60 (7.2%)</td><td>2 (2.1%)</td><td>0.053</td></tr><tr><td>Chronic Kidney Disease</td><td>106 (11.5%)</td><td>97 (11.7%)</td><td>9 (9.4%)</td><td>0.498</td></tr><tr><td>ESRD requiring dialysis</td><td>42 (4.5%)</td><td>37 (4.5%)</td><td>5 (5.2%)</td><td>0.794</td></tr><tr><td>Cirrhosis</td><td>13 (1.4%)</td><td>11 (1.3%)</td><td>2 (2.1%)</td><td>0.636</td></tr><tr><td>Current smoking</td><td>124 (13.4%)</td><td>107 (12.9%)</td><td>17 (17.7%)</td><td>0.191</td></tr><tr><td>Solid cancer</td><td>31 (3.4%)</td><td>28 (3.4%)</td><td>3 (3.1%)</td><td>1.000</td></tr><tr><td>HIV infection</td><td>15 (1.6%)</td><td>15 (1.8%)</td><td>0 (0%)</td><td>0.388</td></tr><tr><td>Hematological malignancy</td><td>17 (1.8%)</td><td>17 (1.9%)</td><td>0 (0%)</td><td>0.243</td></tr><tr><td>Chronicity Scale</td><td>3 (2.4)</td><td>3 (2.4)</td><td>3 (2.3)</td><td>0.173</td></tr><tr><td><strong>Characteristics at ICU admission</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>SAPS II (N=914)</td><td>34 (26.44)</td><td>34 (26.44)</td><td>34.5 (29.44)</td><td>0.433</td></tr><tr><td>SOFA score (N=917)</td><td>4 (2.6)</td><td>4 (2.6)</td><td>4 (2.7)</td><td>0.343</td></tr><tr><td>WHO clinical progression scale<br>(N=920)</td><td>6 (6.8)</td><td>6 (6.8)</td><td>7 (6.8)</td><td>0.188</td></tr><tr><td>Temperature (N=857)</td><td>37 (36.9,38)</td><td>37 (36.9,38)</td><td>37.4 (36.7,38.1)</td><td>0.299</td></tr><tr><td>FiO₂ (%) (N=908)</td><td>90 (60,100)</td><td>90 (60,100)</td><td>100 (70,100)</td><td>0.010</td></tr><tr><td>PaO₂ (mmHg) (N=906)</td><td>73 (61,91)</td><td>72 (61,91)</td><td>76 (63.5,89)</td><td>0.259</td></tr><tr><td>PaO₂/FiO₂ ratio (N=903)</td><td>0.96 (0.7,1.4)</td><td>0.97 (0.70,1.4)</td><td>0.9 (0.7,1.3)</td><td>0.427</td></tr><tr><td>PaCO₂ (mmHg) (N=895)</td><td>37 (32,43)</td><td>37 (32,43)</td><td>38 (34,45)</td><td>0.118</td></tr><tr><td>Lactate (mmol/L) (N=889)</td><td>1.4 (1.2,1.9)</td><td>1.4 (1.2,1.9)</td><td>1.5 (1.1,2.1)</td><td>0.898</td></tr><tr><td>White blood cells (G/L) (N=920)</td><td>8.80 (6.1,12.8)</td><td>8.5 (5.9,12.3)</td><td>11.41 (8.3,14.7)</td><td><strong>&lt;0.0001</strong></td></tr><tr><td>Neutrophils (G/L) (N=736)</td><td>7.8 (5.2,11.3)</td><td>7.44 (5.1,11)</td><td>10.2 (6.4,13.8)</td><td><strong>0.0002</strong></td></tr><tr><td>Lymphocytes (G/L) (N=733)</td><td>0.7 (0.5,1)</td><td>0.7 (0.5,1)</td><td>0.7 (0.5,1.1)</td><td>0.976</td></tr><tr><td>Monocytes (G/L) (N=732)</td><td>0.4 (0.2,0.6)</td><td>0.40 (0.2,0.6)</td><td>0.5 (0.3,0.8)</td><td><strong>0.008</strong></td></tr><tr><td>Oxygen therapy</td><td>51 (5.5%)</td><td>46 (5.6%)</td><td>5 (5.2%)</td><td>0.890</td></tr><tr><td>High Flow Oxygen Therapy</td><td>525 (56.8%)</td><td>474 (57.2%)</td><td>51 (53.1%)</td><td>0.448</td></tr><tr><td>Invasive mechanical ventilation</td><td>441 (47.7%)</td><td>388 (46.8%)</td><td>53 (55.2%)</td><td>0.119</td></tr><tr><td>ARDS</td><td>732 (79.1%)</td><td>643 (77.6%)</td><td>89 (92.7%)</td><td><strong>0.0005</strong></td></tr><tr><td>Shock</td><td>178 (19.2%)</td><td>156 (18.8%)</td><td>22 (22.9%)</td><td>0.335</td></tr><tr><td>Renal replacement therapy</td><td>98 (10.6%)</td><td>88 (10.6%)</td><td>10 (10.4%)</td><td>0.952</td></tr><tr><td>Neuromuscular blockade</td><td>404 (43.7%)</td><td>359 (43.4%)</td><td>45 (46.9%)</td><td>0.511</td></tr><tr><td><strong>ICU management and outcomes</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Duration of hospital stay, days<br>(N=642)</td><td>19.5 (11.37)</td><td>19.0 (11.37)</td><td>22 (13.44)</td><td>0.155</td></tr><tr><td>Duration of stay in the ICU, days<br>(N=655)</td><td>12.0 (6.26)</td><td>11.0 (6.25)</td><td>13.0 (7.31)</td><td>0.157</td></tr><tr><td>Invasive mechanical ventilation</td><td>644 (69.6%)</td><td>576 (69.5%)</td><td>68 (70.8%)</td><td>0.785</td></tr><tr><td>Pronepositioning</td><td>632 (68.3%)</td><td>564 (68%)</td><td>68 (70.8%)</td><td>0.577</td></tr><tr><td>Inhaled nitric oxide</td><td>91 (9.8%)</td><td>82 (9.9%)</td><td>9 (9.4%)</td><td>0.872</td></tr><tr><td>ECMO</td><td>166 (17.95%)</td><td>143 (17.3%)</td><td>23 (23.96%)</td><td>0.105</td></tr><tr><td>Renal replacement therapy</td><td>265 (28.7%)</td><td>238 (28.7%)</td><td>27 (28.1%)</td><td>0.773</td></tr><tr><td>Shock</td><td>507 (54.8%)</td><td>455 (54.9%)</td><td>52 (54.2%)</td><td>0.914</td></tr><tr><td>Duration of vasopressor support,<br>days (N=486)</td><td>7 (3:15)</td><td>7 (3:15)</td><td>8 (3:13)</td><td>0.968</td></tr><tr><td>Death, 28 days</td><td>214 (23.2%)</td><td>196 (23.7%)</td><td>18 (18.8%)</td><td>0.279</td></tr><tr><td>Death, 90 days</td><td>279 (30.3%)</td><td>252 (30.5%)</td><td>27 (28.1%)</td><td>0.630</td></tr></tbody></table>

Qualitative values are shown in number (percentage). Continuous values are shown in median (inter 1-tertile 2; *p*-values come from Chi2, Fisher, Student or Mann-Whitney tests, as appropriate. Hold values are significant at the <0.05 level.

Definition of abbreviations: COPD – chronic obstructive pulmonary disease; ESRD – end-stage renal disease; NSAI – non-steroidal anti-inflammatory; SAPSII – Simplified Acute Physiology Score II; SOFA – Sequential Organ Failure Assessment; WHO – world health organization; ARDS – acute respiratory distress syndrome; RRT – renal replacement therapy; iNO – Inhaled Nitric Oxide; ECMO – extracorporeal membrane oxygenation

*NYHA II-IV; **GFR < 60ml/min/1.73m²

Demographics and characteristics of patients with severe SARS-CoV-2 infection (n = 925) at intensive care unit admission and ICU management and outcomes according to the presence of antibodies against type I IFNs

## CO-59

### Monocytic expression of HLA-DR independently anticipates the clinical course of undifferentiated patients with SARS-Cov-2 in Emergency Department

LAFON Thomas¹, GUÉRIN Estelle¹, CHAPUIS Nicolas², DAIX Thomas¹, FONTENAY Michaela², VIGNON Philippe¹, FRANÇOIS Bruno¹, FEUILLARD Jean¹

¹CHU Dupuytren, Limoges, France; ²Hôpital Cochin, AP-HP, Paris, France

**Correspondence:** Thomas LAFON (thomas.lafon@chu-limoges.fr)

Annals of Intensive Care 2022, 12(1):CO-59
**Rationale:** Assessing the prognosis of patients with SARS-Cov-2 related pneumonia is fundamental in Emergency Department (ED) to manage the flow of patients. Previous cohort of patients highlighted that 1/3 of patients worsened after their admission. Standard scores and biomarkers used in ED are strongly associated with immediate severity but their prognostic performance to predict clinical course of patients is limited. COVID-19 leads to immunological impairment with lymphopenia, low expression of HLA-DR on monocytes and high neutrophil count. We evaluated the prognostic performance of immunological parameters (circulating lymphocyte subsets, neutrophils and immature granulocytes, MO1 immature to M3 inflammatory stage based on CD16 and CD14 expression, and mHLA-DR) to anticipate the clinical evolution of undifferentiated COVID-19 patients in ED.

**Patients and methods/Materials and methods:** We conducted a prospective multicenter study during 5 months in two ED: one for exploratory cohort and one for consolidation. In addition to clinical, biological and radiological parameters, circulating lymphocyte subsets, mature and immature granulocytes and mHLA-DR were analyzed using routine flow cytometry on the first blood sample. The primary endpoint was the non-deterioration determined by 3 clinicians who were blinded from cytometry results and defined from a composite criterion: (i) need for high flow oxygen, (ii) ICU admission, (iii) in-hospital mortality related to SARS-COV-2, (iv) readmission within 5 days. Sample size of 245 patients (estimated deterioration = 20%).

**Results:** 284 patients were analyzed (men = 56%; mean age = 63 ± 17 yrs; onset of symptoms 7 ± 4 days, SpO₂ = 95 ± 4%, respiratory rate = 23 ± 7 breaths/min) including 72 patients (25%) who were assigned to the deterioration group (high flow oxygen 86%, ICU admission 35%, in-hospital mortality 40%, readmission 8%). On the first series of 180 patients, among the 27 clinical and biological parameters tested, the 3 independent variables were P/F ratio (adjusted OR = 2.8, LCI = 1.2, UCI = 6.4, p = 0.014), lymphocyte count (adjusted OR = 4.2, LCI = 1.7, UCI = 10.2, p = 0.0019) and mHLA-DR (adjusted OR = 4.5, LCI = 2, UCI = 10.3, p = 0.0003). On the consolidating series of 104 patients, the independent variables were also P/F ratio (adjusted OR = 9.2, LCI = 3, UCI = 19, p = 0.0001), lymphocyte count (adjusted OR = 4, LCI = 1, UCI = 16, p = 0.049) and mHLA-DR (adjusted OR = 4.1, LCI = 1.2, UCI = 13.7, p = 0.02). A score that included P/F ratio > 300, lymphocyte count > 1.1 G/L and HLA DR intensity > 15 000 reached 100% of PPV for non-deterioration.

**Conclusion:** With the P/F ratio and the lymphocyte count, absence of DR loss on monocytes was strongly independently and robustly associated with clinical non-deterioration. A simple predictive score ratio seems interesting to allow safe rule-out, over-triage reduction and better allocation of hospital resources.

**Compliance with ethics regulations:** Yes in clinical research.

## CO-60

### Incidence and outcome of invasive pulmonary aspergillosis in critically-ill COVID-19 patients: a French multicenter experience

DESMEDT Luc<fnref n="1" />, RAYMOND Matthieu<fnref n="1" />, ASFAR Pierre², DARREAU Cedric<fnref n="1" />, REIZINE Florian³, COLIN Gwenhaël⁴, AUCHABIE Johann¹³, LACOMBE Béatrice¹², KERGOAT Pierre¹¹, HOURMANT Baptiste⁶, DELBOVE Agathe⁷, FRÉROU Aurélien⁸, MORIN Jean¹⁵, ERGRETEAU Pierre Yves⁹, SEGUIN Philippe¹⁰, REIGNIER Jean<fnref n="1" />, LASCARROU Jean-Baptiste<fnref n="1" />, CANET Emmanuel<fnref n="1" />

Polyvalente, CH du Mans, Le Mans, France; ¹⁵Unité de soins intensifs de Pneumologie, Nantes, France

**Correspondence:** Luc DESMEDT (Luc.desmedt@live.fr)

Annals of Intensive Care 2022, **12**(1):CO-60

**Rationale:** Recent studies identified coronavirus disease 2019 (COVID-19) as a risk factor for invasive pulmonary aspergillosis (IPA), with conflicting data on prevalence and impact on patients' outcomes. We aimed to determine the incidence and outcome of COVID-19 associated pulmonary aspergillosis (CAPA) in mechanically ventilated COVID-19 patients.

**Patients and methods/Materials and methods:** We conducted a multicenter observational study. All Covid-19 patients admitted to 15 ICUs from Pays-de-la-Loire and Bretagne regions between February 1st 2020 and December 31st 2020 and treated with mechanical ventilation were included. The main objective was to assess the incidence and mortality of CAPA in COVID-19 patients with acute respiratory distress syndrome (ARDS). Each case of CAPA reported by local investigators was reviewed by an adjudication committee of 3 independent experts. CAPA were diagnosed and graded according to the 2020 ECMM/ISHAM consensus criteria [1].

**Results:** Among the 15 participating centers, 2 (13%) had a screening strategy for Aspergillus in mechanically ventilated patients, while in the other 13 (87%) centers CAPA was investigated in case of respiratory deterioration. During the study period, 644 mechanically ventilated patients were included (mean age 65 (SD 11) years-old; 523 (74%) men). Mean duration of mechanical ventilation was 21 (19) days and 90-day mortality rate was 34%. According to the EORTC criteria, 114 (16%) patients had underlying immunosuppression. Overall, 348 (49%) patients were treated with corticosteroids and no patients received Tocilizumab. Overall, 35 (5%) patients had proven/probable/possible CAPA. Among them, 18 (3%) patients fulfilled the criteria for probable CAPA and 17 (3%) patients met the criteria for possible CAPA (3%). No case of histologically proven CAPA was reported. Patients with probable CAPA were 70 (7) years-old and 4 (22%) were immunocompromised. Patients with possible CAPA were 68.64 (8.62) years-old and 3 (17.6%) were immunocompromised. Probable CAPA were diagnosed after 8 [4.25-21.75] days of mechanical ventilation and possible CAPA after 6 [1-10] days. At day-90, 16 (46%) of the 35 patients with CAPA were dead. Among the 18 patients with probable CAPA, the mortality at day-90 was 55% (n = 10) and the duration of mechanical ventilation was 27 [18-33.5] days. Patients with possible CAPA had a mortality rate at day-90 of 35% (n = 6) and a duration of mechanical ventilation of 16 [13-23] days.

**Conclusion:** In our study, the incidence of IPA in ARDS-Covid-19 patients treated with mechanical ventilation was low, and only probable CAPA was associated with a higher mortality at day-90.

**Reference 1:** Koehler, Philipp, Matteo Bassetti, Arunaloe Chakrabarti, Sharon C A Chen, Arnaldo Lopes Colombo, Martin Hoenigl, Nikolay Klimko, et al. « Defining and managing COVID-19-associated pulmonary aspergillosis: the 2020 ECMM/ISHAM consensus criteria for research and clinical guidance. Lancet Infect Dis 2021; 21: e149-e162.

**Compliance with ethics regulations:** Yes in clinical research.

## CO-61

### Psychotraumatic impact of the child's visit to the adult intensive care unit: first results of the ENVIFAR study

NGUYEN Stéphanie<fnref n="1" />, VANGI Marie-Aude², FOURNIER Alicia<fnref n="1" />, SOUPPART Virginie⁴, PILI FLOURY Sébastien², QUENOT Jean Pierre⁶, DUBOST Jean-Louis⁷, BOUHEMAD Belaid⁸, CAPELLIER Gilles⁹, LAURENT Alexandra²,¹⁰

**Correspondence:** Stéphanie NGUYEN (stephanielaurent@gmx.fr)

<footnote n="1">¹Service de Médecine Intensive Réanimation, CHU de Nantes, Nantes, France; ²Service de Médecine Intensive Réanimation, CHU d'Angers, Angers, France; ³Service de Médecine Intensive Réanimation, CHU de Rennes, Rennes, France; ⁴Service de Réanimation Polyvalente, CHD La Roche Sur Yon, La Roche Sur Yon, France; ⁵Service de Réanimation Polyvalente, CH Saint Nazaire, Saint Nazaire, France; ⁶Service de Réanimation Polyvalente, CHU de Brest, Brest, France; ⁷Service de Réanimation Polyvalente, CH de Vannes, Vannes, France; ⁸Service de Réanimation Polyvalente, CH de Saint Malo, Saint Malo, France; ⁹Service de Réanimation Polyvalente, CH de Morlaix, Morlaix, France; ¹⁰Service de Réanimation chirurgicale, CHU de Rennes, Rennes, France; ¹¹Service de Réanimation Polyvalente, CH de Cornouille, Quimper, France; ¹²Service de Réanimation Polyvalente, CH Bretagne Sud, Lorient, France; ¹³Service de Réanimation Polyvalente, CH Cholet, Cholet, France; ¹⁴Service de Réanimation</footnote>

<footnote n="1">¹Université Bourgogne Franche-Comté, Dijon, France; ²CHU Dijon, Réanimation Chirurgicale, Dijon, France; ³Université Bourgogne Franche-Comté, Laboratoire Psy-DREPI, Dijon, France; ⁴APHP Saint Louis, Médecine Intensive Réanimation, Paris, France; ⁵CHU Besançon, Réanimation Chirurgicale, Besançon, France; ⁶CHU Dijon, Médecine Intensive Réanimation, Dijon, France; ⁷CH Pontoise, Réanimation Médico-Chirurgicale, Pontoise, France; ⁸CHU Dijon, Réanimation Chirurgicale, Dijon, France; ⁹CHU Besançon, Réanimation Médicale, Besançon, France; ¹⁰Université Bourgogne Franche-Comté, Laboratoire Psy-DREPI, Dijon, France</footnote>
Annals of Intensive Care 2022, **12**(1):CO-61

**Rationale:** While Intensive Care Units (ICU) have widely opened their doors to relatives, the presence of visiting children and adolescents in ICU remains a sensitive issue. In a desire to protect the child from a potentially traumatic environment, some units refuse or restrict visits to children (Laurent et al., 2019). The aim of this study is to measure the psychotraumatic impact of a child's visit to adult ICU and to identify the influence of the accompanying parent on the child's visit.

**Patients and methods/Materials and methods:** This study was conducted in six ICU with 22 children, 15 accompanying parents. The psychotraumatic impact of the visit on the child was measured at 7 and 30 days of the visit using the CRIES-8 (Children's revised impact of event scale, CRIES-8). We also measured the anxiety-depression of the accompanying parent during the visit using the HADS (REF). We complemented the quantitative approach with semi-structured interviews to capture the experience of the visit at 7 days.

**Results:** Of the 22 children included, 15 children were able to complete questionnaires at 7 days of the visit and 21 at 30 days. At 7 days of the visit, 9 out of 15 children showed acute stress. One month after, 9 out of 21 children suffered from a potential post-traumatic stress disorder. The thematic analysis shows that the visit is indeed disturbing for most of children. However, children expressed that this visit was reassuring to them. Certain dimensions are identified as a source of distress and can explain the CRIES-8 scores: the absence of the hospitalized parent, the distress of the accompanying parent, and the disruption of daily life. In the same sense, our study shows a positive trend correlation between the HADS scores of the accompanying parents and the CRIES-8 score of the children (r2 = .24, p = .062) at 7 days. Thus, the higher the anxiety-depressive symptomatology of the parents, the higher the acute stress symptomatology of the children tended to be.

**Conclusion:** More than the visit itself, these initial results show the importance of considering the visiting parent's experience during the child's visit.

**Reference 1:** Laurent A., Leclerc P., Nguyen S., Capellier G. (2019) The effect visiting relatives in the adult ICU has on children. Intensive Care Medicine. https://doi.org/10.1007/s00134-019-05690-2.

**Reference 2:** Laurent A., Nguyen S., Leclerc P., Capellier G. (2020) L'enfant visiteur en réanimation adulte: vécu psychologique de la visite et dispositifs d'accompagnement. Pratiques psychologiques (2020).

**Compliance with ethics regulations:** Yes in clinical research.

## CO-62

### Measuring ethical decision-making climate before and after the implementation of therapeutic perspective meetings—

#### CLIMETHIC study

VALBRUN Jean-David¹, NGUYEN Yên-Lan²

¹Gustave Roussy, Villejuif, France; ²CHU Cochin, Paris, France

**Correspondence:** Jean-David VALBRUN (jean-david.valbrun@orange.fr)

Annals of Intensive Care 2022, **12**(1):CO-62

**Rationale:** The perception of inappropriate care in end-of-life situations can be a source of conflict and burnout among caregivers. The purpose of this study is to describe caregivers' perceptions of end-of-life care in the surgical intensive care unit and intermediate care unit of our hospital before and after the implementation of therapeutic perspective meetings (TPMs).

**Patients and methods/Materials and methods:** Caregivers in the ICU were invited to participate in this survey before (August to October 2018) and after (August to October 2019) the implementation of TPMs. The "ethical decision-making climate" self-questionnaire was used. It explores 3 dimensions: working conditions, managerial skills and end-of-life decision making. Descriptive and analytical analyses were performed. This study was approved by the SFAR ethics commission (opinion n° IRB 00010254-2017-133).

**Results:** The implementation of TPMs improved caregivers' perception of the existence of regular meetings to discuss projects (2 vs 3, p < 0.0001) and the quality of care delivered (2 vs 3, p < 0.0026). TPMs improved caregivers' perception of expressing disagreement with opinions or values (3 vs. 3, p = 0.02), nurses' presence during end-of-life interviews (3 vs. 3.5; p = 0.003) and nurses' involvement in these decisions (2 vs. 3, p < 0.0001). The TPMs did not change caregivers' perception on the medical team management, on the realization of formalized debriefings after a difficult care or end-of-life situation, on the temporality of end-of-life decisions or on the admissions of patients with minimal chances of recovery.

**Conclusion:** The implementation of TPMs has improved the perception of caregivers regarding communication between caregivers on patient management, particularly for end-of-life situations, and has encouraged the involvement of nurses in these decisions as well as their presence during interviews with the families. There was no impact on perceptions of the temporality of end-of-life decision-making or on admissions of patients with minimal chance of recovery. Further studies are needed to assess the impact of TPMs on the prevalence of conflict, risk of burnout, and quality of care delivered.

**Reference 1:** Piers et coll., JAMA, 2011.

**Reference 2:** Bo Van den Bulcke and coll. BMJ, 2018.

**Compliance with ethics regulations:** Yes in clinical research.

<figure><img src="image_27.png" /><figcaption>Comparaison avant-après</figcaption></figure>

## CO-63

### Intensivists' differential ethical perceptions about withholding and withdrawing of treatment (Wh&Wd) decisions: a clinical ethics empirical investigation

SPRANZI Marta¹

¹AP-HP, Paris, France

**Correspondence:** Marta SPRANZI (marta.spranzi-ext@aphp.fr)

Annals of Intensive Care 2022, **12**(1):CO-63

**Rationale:** Intensive care professional societies have issued policy recommendations regarding Wh&Wd decisions that consistently classify them as ethically equivalent and ethically neutral insofar as they correspond to "passive" actions. However, on the ground some are perceived as more "active" than others most notably Wd as opposed to Wh decisions. Recent studies also show that there is a personal "variability" in the way such decisions are made, and that further investigation is needed. Therefore it seemed necessary to explore intensivists' differential ethical perceptions about Wh&Wd decisions and the ethical reasons underlying their spontaneous judgments.

**Patients and methods/Materials and methods:** A qualitative retrospective and multicentered study was initiated in 7 AP-HP intensive care units. In-depth interviews were conducted with 39 intensivists of different age groups and levels of professional experience, and with 5 department heads. We used an inductive ("grounded theory" inspired), multidisciplinary clinical ethics approach, aimed at eliciting and retrieving practitioners' ethical intuitions about different Wh&Wd decisions. Interview transcripts were analyzed using a "thematic analysis" approach.
**Results:** Practitioners' perceptions of Wh&Wd decisions vary along two continuous dimensions: "active"/passive and ethically problematic/unproblematic. Three groups have been identified and described: those who tend to consider Wh&Wd decisions (1) as passive and unproblematic, (2) as active and problematic, and (3) as active and unproblematic. More interestingly, these groups are differently correlated with three other ethically relevant variables: the role of consensus during the collegial procedure, the difference between withholding and withdrawing decisions, and the definition of one's own overarching goal as professional.

**Discussion:** The study results confirm what is now called practitioners' "variability" and the moral complexity of Wh&Wd decisions. Moreover, it shows that, contrary to the "moral neutrality" doctrine, practitioners consider different Wh&Wd decisions as more or less morally problematic along a continuum from passive to "very active", although Wd&Wh practices are mostly described as different from euthanasia. It also shows that practitioners' "variability" does not simply correspond to sociological variables which could be easily erased, but has deep-seated ethical roots.

**Conclusion:** Practitioners' perception and ethical reasons about Wh&Wd decisions have never been analyzed in depth. Our results allow for the recognition of intensivists' moral distress about Wh&Wd decisions, and open up new perspectives to deal with their deep-rooted variability, most notably by working on the rationale and format of the collegial procedure.

**Reference 1:** Nadig, N. R., & Ford, D. W. (2019). A Consensus: Everyone Agrees Collectively but No One Believes Individually. Critical care medicine, 47(10), 1470–1472.

**Reference 2:** Wilkinson, D. J., & Truog, R. D. (2013). The luck of the draw: physician-related variability in end-of-life decision-making in intensive care. Intensive care medicine, 39(6), 1128–1132.

**Compliance with ethics regulations:** N/A.

<figure><img src="image_28.png" /><figcaption>Ethical perceptions of WD&Wd decisions and intensivists' values</figcaption></figure>

CO-64

**Association of nursing team composition with mortality in critically ill patients: a multicenter observational study**

GUÉRIN Claude<fnref n="1" />,<fnref n="5" />, PAYET Cécile<fnref n="5" />, BABOI Loredana³, ALLAOUCHICHE Bernard<fnref n="2" />, ARGAUD Laurent<fnref n="1" />, AUBRUN Frédéric³, BOHÉ Julien<fnref n="2" />, DAILLER Frédéric⁴, FELLAHI Jean-Luc⁴, LEHOT Jean-Jacques<fnref n="5" />, PIRIOU Vincent<fnref n="2" />, RIMMELÉ Thomas<fnref n="1" />, POLAZZI Stéphanie<fnref n="5" />, DUCLOS Antoine<fnref n="5" />

**Correspondence:** Claude GUÉRIN (claude.guerin@chu-lyon.fr)

Annals of Intensive Care 2022, **12**(1):CO-64

**Rationale:** In the Intensive Care Unit (ICU), patient-to-nurse ratio is associated with patient outcomes but little is known about the habit among staff members of working together. The goal of present study is to investigate the role of nursing team composition on patient ICU mortality.

**Patients and methods/Materials and methods:** Retrospective multicentre observational study in eight adult ICUs from the Greater Lyon

area in France, analysing all patients present between January 1st 2011 and December 31st 2016. The team composition was evaluated using the familiarity among the ICU caregivers, which was measured by shift (from 7:00 am to 6:59 pm and from 7:00 pm to 6:59 am) as the mean number of previous collaborations between each nursing team member during previous shifts within the given ICU. Suboptimal collaboration was defined as less than 50. The patient-to-nurse ratio and patient-to-auxiliary nurse ratio were also considered (suboptimal ratio defined as higher than 0.5 and 0.25, respectively), as well as individual length of experience in ICU for every caregiver (suboptimal defined as less than 400 previous shifts with collaboration). The primary outcome was inpatient death at the time of ICU discharge, excluding patients for whom a decision to forego life-sustaining therapy was made. Inpatient death during the shift at admission was secondarily considered. A multiple Poisson regression was computed to identify the determinants of ICU mortality per shift, taking into account the ICU site, patients' characteristics, and caregivers' workload.

**Results:** A total of 43,479 patients were admitted to the ICUs of whom 3,311 (7.6%) died, corresponding to 8.8% shifts (3,101/35,072) with at least one death. The adjusted model showed an increased risk of patient mortality during shifts exposed to suboptimal team familiarity lower than 50 previous collaborations (Relative Risk 1.06, 95% Confidence Intervals [1.04–1.09]) and simultaneously with suboptimal patient-to-staffing ratio (RR 1.13, IC95% [1.07–1.19]). Suboptimal team composition reflected a total of 172 [116–241] shifts with potentially avoidable death, corresponding to 7.5% of all ICU shifts with occurrence of inpatient death. The risk of death at admission was also higher in case of suboptimal team composition (RR 1.27, IC95% [1.13–1.43]).

**Conclusion:** In conclusion, the familiarity between ICU nursing staff is significantly associated with inpatient death additionally to patient-to-caregiver ratio. Improving team composition should be a management goal in ICU.

**Compliance with ethics regulations:** Yes in clinical research.

<figure><img src="image_29.png" /><figcaption>Figure 1</figcaption></figure>

CO-65

**Healthcare workers cost awareness in intensive care unit: a prospective multicentric study**

GABARRE Paul<fnref n="1" />, MAYLIN Rima<fnref n="1" />, STUDER Antoine<fnref n="2" />, GUITTON Christophe³, ANTIGNAC Marie<fnref n="1" />, DE PROST Nicolas⁴, URBINA Tomas<fnref n="1" />, BONNY Vincent<fnref n="1" />, MISSRI Louai<fnref n="1" />, EHRMINGER Sebastien<fnref n="1" />, BAUDEL Jean-Luc<fnref n="1" />, JOFFRE Jérémie<fnref n="1" />, AIT OUFELLA Hafid<fnref n="1" />, MAURY Eric<fnref n="1" />

**Correspondence:** Paul GABARRE (paulqabarre@hotmail.com)

Annals of Intensive Care 2022, **12**(1):CO-65

**Rationale:** Physicians play an important role in controlling health care spending, by prescribing more or less expensive treatments. The aim of this study was to evaluate the knowledge of health care workers of the cost of the treatments they daily use in ICU.

**Patients and methods/Materials and methods:** We conducted a prospective, multicenter, volunteer-based study. A survey was delivered and completed anonymously by healthcare workers

<footnote n="1">¹Hôpital Edouard Herriot Hospices Civils de Lyon, Lyon, France, France;</footnote>

<footnote n="2">²Groupement hospitalier Lyon Sud, Lyon, France; ³Groupement hospitalier nord, Lyon, France; ⁴Groupement hospitalier Est, Lyon, France;</footnote>

<footnote n="5">⁵Université de Lyon, Lyon, France</footnote>

<footnote n="1">¹Hôpital Saint Antoine, Paris, France; ²CHRU Strasbourg, Strasbourg, France; ³Centre Hospitalier du Mans, Le Mans, France; ⁴Hôpital Henri Mondor, Créteil, France</footnote>
(HCWs) of four French ICUs, three university affiliated and one non-university affiliated. The survey proposed to estimate the price of 37 treatments frequently used in critical care. Cost estimations were expressed as percentage of the real cost; an estimation was considered correct if it was ± 50% of the true prices

**Results:** 158 HCWs answered to the survey, including 75 nurses and 82 physicians. Medical staff was composed of 36 seniors and 45 juniors. Median age of the respondents was 29 [25–36] years. They provided 5798 answers. Only 18% of estimations were within 50% of the real cost. In univariate analysis, Medical staff was more likely to respond correctly than nurses, with 20% vs. 16,8% of correct cost estimations (p = 0,001). Unsurprisingly, among the medical staff, seniors were better at evaluating the prices than juniors, with 22,58% of good answers vs. 18,3% p = 0,0051. There was no difference between university affiliated and non-university affiliated hospital's HCWs. Antibiotics were the most often well estimated treatments, with 25% of correct estimations, followed by fluids (24%), vasopressors (19%), sedative drugs (14%), chemotherapy and immunosuppressive treatments (13%). Interestingly, the most expensive treatments prices were under evaluated whereas the cheapest ones were overvalued. For example, median estimation of the cost of eculizumab was only 9 [2,5–29]% of its real price.

**Conclusion:** ICU health care workers have a poor knowledge of the price of treatments frequently used in the ICU.

**Compliance with ethics regulations:** N/A.

## CO-66

### How subjective determinants influence antibiotic prescribing behaviors among intensivists in French ICUs? A nation-wide cross-sectional survey

GIANNOLI Alice¹, BAUDOT Amandine¹, THIERY Guillaume¹

¹CHU Nord Saint-Etienne, Saint Etienne, France

**Correspondence:** Alice GIANNOLI (alice.giannoli@gmail.com)

*Annals of Intensive Care* 2022, **12**(1):CO-66

**Rationale:** In order to improve antibiotic's use, strategies, such as stewardship programs, have been developed. However, their efficacy remains flawed and antibiotics remain overused. One of the reasons lies in subjective determinants of the prescription. The aim of our study is to explore personal, social, cultural and contextual factors that can influence antibiotic prescribing behaviour in the ICU.

**Patients and methods/Materials and methods:** For this nation-wide study, we designed a questionnaire to explore 4 domains that may influence antibiotic prescription: demographic characteristics, knowledge and medical practice, social interactions, and psychological factors. The questionnaire was distributed to all ICUs in France through a personal email sent to the head of each ICU, asking them to send the questionnaire to doctors and residents of their team. Two reminders were sent, at 2 and 4 months.

**Results:** We received 803 responses (55% senior physicians, 15% fellows, 5% academic physicians and 25% residents). Primaries specialties was anesthesiology (47%), medical specialty (38%), emergency medicine (8%) and intensive care (DESMIR, 7%). Fifty-two percent worked in university hospitals, 41% had a combined activity. The population is comparable to the global demography in French ICUs (1). A large majority (84%) of the respondents felt concerned by antibiotic resistance, but 45% didn't believe that a restrictive use could decrease it. Only 54% of the responders shared the statement "we must always seek the narrowest spectrum". The decision to not initiate an antibiotic treatment was perceived as more difficult that initiating, adapting of interrupting it (p < 0.0001). For 85% of the responders, antibiotic prescription is a team decision. However, 30% declare that they don't ask any advice and 22% report a large variability within their team. Twenty-two percent of the responders don't hesitate to modify a prescription of their college and 13% of their boss if considered inappropriate. Seventy-eight percent of the responders consider themselves

as "restrictive prescribers". More academic physicians, senior physicians and physician having validated the subspecialisation in intensive care (DESC) declared themselves as "restrictive prescribers", whereas more residents declared themselves "liberal prescribers". Analysis of these "liberal prescribers" reveals that they are significantly more inexperienced, anxious and insecure, with a limited ability to take a step back.

**Conclusion:** This work confirms that subjective determinants hinder reasoned antibiotic prescribing. Factors such as prescriber anxiety and lack of self-confidence, linked in particular to a lack of knowledge, stand out. The fear of missing a septic etiology pushes the physician to prevail the short-term benefit taking over the long-term consequences.

**Compliance with ethics regulations:** Yes in clinical research.

## CO-67

### Assessment of new methods for bedside measurement of airway opening pressure without the need for low-flow insufflation

HAUDEBOURG Anne-Fleur¹,³, DELAMAIRE Flora², LOUIS Bruno³, MEKONTSO DESSAP Armand¹,³, CARTEAUX Guillaume¹,³

¹C.H.U. HENRI MONDOR, Creteil, France; ²HÔPITAL PONTCHAILLOU, Rennes, France; ³INSTITUT MONDOR DE RECHERCHE BIOMEDICALE (IMRB), Creteil, France

**Correspondence:** Anne-Fleur HAUDEBOURG (annefleur.maignant@aphp.fr)

*Annals of Intensive Care* 2022, **12**(1):CO-67

**Rationale:** The gold standard method proposed to detect and measure airway opening pressure (AOP) in patients with acute respiratory distress syndrome (ARDS) requires a low-flow insufflation (i.e., 5 L/min). This ensures that the resistive pressure is negligible but might potentially be poorly tolerated. Theoretically, during usual constant flow insufflation (i.e., 30 to 60 L/min), the delta pressure comprised between the PEEP and the first inflection point of the airway pressure waveform, subsequently called "conductive pressure", comprises resistive pressure and potential AOP (Fig. 1). We assessed the accuracy and tolerance of calculating AOP as the conductive pressure minus resistive pressure during usual constant flow insufflation. We also assessed an automated computer-based detection of AOP.

**Patients and methods/Materials and methods:** AOP was measured in ARDS patients using three different methods: 1: gold standard: low-flow insufflation (5 L/min); 2: visual waveform analysis during standard ventilation with a constant flow rate of 30 and 60 L/min: AOP was identified as the conductive pressure minus the resistive pressure; 3: automated computer-based detection of the rupture of the airway pressure slope. We compared methods 2 and 3 to the gold standard and collected the lowest SpO₂ during each measurement to assess the tolerance.

**Results:** 25 ARDS patients were included so far, of whom 13 (52%) had an AOP > 5 cmH₂O with a median value of 7 cmH₂O [6–8]. AOP obtained by visual waveform analysis during ventilation with usual flow rate showed a very strong correlation with reference value (r = 0.8 at flow 30 L/min and r = 0.93 at flow 60 L/min, p < 0.001, Fig. 1). Bland–Altman plot for visual waveform analysis at 60 L/min showed a bias of 0.08 with agreement limits between – 1.87 and 2.03 cmH₂O. AOP obtained by computer-based detection showed a strong correlation with reference value (r = 0.66 at 30 L/min and r = 0.70 L/min, p < 0.001) but with a trend toward overestimation of AOP. Visual or computer-based waveform analysis during ventilation with usual flow rate was better tolerated than gold standard method (decrease in SpO₂: – 0.5% [– 2–0] and 0% [– 2–0] at 30 and 60 L/min respectively versus – 2% [– 4.8 to – 1] at 5 L/min, p < 0.001).

**Conclusion:** These preliminary data suggest that measuring AOP is feasible at standard insufflation flow rate with a simple, quick and safe method based on visual inspection of airway pressure waveform.

**Compliance with ethics regulations:** Yes in clinical research.
<figure><img src="image_30.png" /><figcaption>Figure 1: Spearman correlation between AOP obtained by visual wave-form analysis during standard ventilation at 60 L/min and gold standard at low-flow insufflation (full line: linear regression line).</figcaption></figure>

CO-68

Detection and respiratory mechanic assessment of asymmetrical
acute respiratory distress syndrome with electrical impedance
tomography

ROZE Hadrien¹, BONNARDEL Eline¹, BOISSELIER Clément¹, GRESS
Gauthier¹, REPUSSEAU Benjamin¹, PERRIER Virginie¹, CHRISTELLE Pellerin¹,
QUATTARA Alexandre¹

¹CHU de Bordeaux, Bordeaux, France

**Correspondence:** Hadrien ROZE (hadrien.roze@chu-bordeaux.fr)

Annals of Intensive Care 2022, **12**(1):CO-68

**Rationale:** ARDS is a heterogeneous syndrome involving differ-
ent phenotypes with distinct clinical and outcome characteristics.
Low flow pressure volume (PV) curve reflects the global behavior of
the lungs and can be misleading in ARDS. With Electrical Impedance
Tomography (EIT) it is possible to measure the distribution of ventila-
tion in each lung in order to describe asymmetrical lung injury. Moreo-
ver, each lung respiratory mechanic and PV curve can be assessed with
an EIT derived method. In the present study, we hypothesized that
some patients may have asymmetrical ARDS where EIT would provide
different information from those obtained from global P-V curves.

**Patients and methods/Materials and methods:** Prospective study (NCT04386720). We recorded the low flow PV curve without PEEP of the ventilator in order to assess airway closure and the recruited volume.¹ AT the same time with EIT we analyzed the derived PV curves of each lung.² A difference of tidal ventilation of at least 20% between the 2 lungs was considered as asymmetrical ARDS. We compared respiratory mechanic between the 2 lungs in patients with asymmetrical ARDS.

**Results:** We analyzed 26 patients, 18 patients had asymmetrical lung injury, the most injured lung received 28.5±8.0% of the tidal ventilation, its compliance was significantly lower than the less injured lung: 11.9±7.8 vs 28.8±14.3 ml cmH₂O-1p<0.0001 respectively. Thirteen patients had airway closure with an airway opening pressure >4 cmH₂O; Global PV curve AOP was 6.6±3.4 cmH₂O, similar to the less injured lung with 6.6±3.3 cmH₂O, whereas the most injured lung had a significantly higher AOP of 10±3.9, p=0.003. The PEEP recruited volume V<sub>REC</sub> was significantly lower in the most injured lung: 67 [43–123] vs 120 [57–225] ml, p=0.015. The compliance of the recruited lung (Crec) in the more injured lung was not different from the less injured 22.0 [5.6–32.3] vs 24.0 [11.8–41.0] ml.cmH₂O-1 respectively, p=0.460.

**Conclusion:** EIT can show asymmetrical ARDS and assess respiratory mechanic of each lung. Personalizing ventilator management in asymmetrical lung injury entails assessing each lung-specific risk of VILI with repeated opening and collapse of the most injured lung and overdistension in the less injured lung. A specific compromise between PEEP

and VT in asymmetrical ARDS could attenuate these opposite risk of
VILI.

**Reference 1:** AJRCCM 2018 197:132–136.

**Reference 2:** AJRCCM 2021;203:511–515.

**Compliance with ethics regulations:** Yes in clinical research.

<figure><img src="image_31.png" /><figcaption>Airway Opening Pressure measured with EIT in each lung</figcaption></figure>

CO-69

Response to PEEP assessed on computed tomography
in COVID-19 ECMO patients

RICHARD Jean-Christophe¹,², YONIS Hodane¹, SIGAUD Florian³, MEZIDI Mehdi¹, DAVILA SERRANO Eduardo², ORKISZ Maciej², ROUX Emmanuel², GAILLET Maxime¹, BAYAT Sam³, TERZI Nicolas³, BITKER Laurent ¹,²

¹Hôpital de la Croix-Rousse, Lyon, France; ²Université de Lyon, Université Claude Bernard Lyon 1, INSA-Lyon, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1206, Lyon, France; ³CHU Grenoble Alpes, Grenoble, France

**Correspondence:** Jean-Christophe RICHARD (j-christophe.richard@chu-lyon.fr)

Annals of Intensive Care 2022, 12(1):CO-69

**Rationale:** Lung potential for recruitment of COVID-19 ARDS is a matter of debate, and may be patient-dependent, favoring individualization of PEEP setting. PEEP selection in severe COVID-19 patients under ECMO may be more challenging as no study has assessed recruitment potential in this setting. The aim of the study was to compare potential for recruitment and the impact of PEEP on lung aeration with computed tomography (CT) in moderate, severe without ECMO and severe under ECMO ARDS patients.

**Patients and methods/Materials and methods:** We conducted a two-center prospective observational study in adult COVID-19 related ARDS patients who had an indication for CT. Main exclusion criteria were ARDS onset > 72 h in non-ECMO patients or ECMO onset > 72 h Four low-dose CT acquisitions were performed at both end-expiration and end-inspiration at PEEP selected by attending physician, and at end-expiration at both PEEP 5 and 15 cmH₂O.

**Results:** 99 patients (76% male, age 62 [54–71] year) were included, of whom 24 had severe ARDS under ECMO, 59 severe ARDS without ECMO and 16 moderate ARDS. ECMO patients were ventilated with significantly lower tidal volume (1.0 [1.0–1.0] vs 6.0 [5.9–6.0] ml/ kg predicted body weight (PBW) and higher PEEP (15 [13–15] vs. 10 [5–10] cmH₂O. The median amount of recruitable lung between PEEP 5 and 15 cmH₂O was 6.2 [4.0–9.9]% of lung weight, and tidal hyperinflation amounted to 0.3 [0.1–1.0] ml/kg PBW. Tidal hyperinflation > 1 ml/ kg PBW was observed in 19 (25%) non-ECMO patients and 0 (0%) ECMO patients. Non-inflated lung at PEEP 5 was significantly greater in ECMO than in non-ECMO patients (Fig. 1). End-expiratory aerated lung volume (EELV) at PEEP 5 was significantly lower in ECMO patients.
Recruitment induced by PEEP increase from 5 to 15 cmH₂O was not significantly different between groups, while PEEP-induced hyperinflation was significantly lower in the ECMO group and virtually inexistent. Tidal hyperinflation was significantly lower in ECMO patients. Compliance of the aerated lung between 5 and 15 cmH₂O corrected for lung recruitability (CompliancePEEP5-15) was significantly lower in ECMO patients and was independently related to lung aeration at PEEP5 in multivariate analysis.

**Conclusion:** Lung recruitability of COVID-19 pneumonia is not significantly different among class of ARDS severity. ECMO patients exhibits lower hyperinflation levels of already aerated lung with PEEP increase from 5 to 15 cmH₂O, as a consequence of compliance decrease of the baby lung at low end-expiratory lung volume. This suggests that PEEP higher than 15 could be safely applied in COVID-19 severe ARDS ECMO patients.

**Compliance with ethics regulations:** Yes in clinical research.

<figure><img src="image_32.png" /><figcaption>Figure 1</figcaption></figure>

**CO-70**
**Physiological effects of positive end-expiratory pressure titration strategies based on electrical impedance tomography in patients with COVID-19 associated acute respiratory distress syndrome**

COURTAIS Antonin¹, CHEAN Dara¹, PAVLOVSKY Bertrand¹, LESIMPLE Arnaud¹, RICHARD Jean Christophe¹, MERCAT Alain¹, BELONCLE François¹
¹CHU Angers, Angers, France

**Correspondence:** Antonin COURTAIS (courtais.antonin@gmail.com)

Annals of Intensive Care 2022, **12**(1):CO-70

**Rationale:** Electrical Impedance Tomography (EIT) allows to provide an imaging of the gas distribution in the lung during ventilation. Various EIT-based strategies have been proposed to titrate positive end-expiratory pressure (PEEP) in patients with acute respiratory distress syndrome (ARDS). This study aimed to compare the physiological effects of two distinct EIT-based and one respiratory system mechanics-based PEEP titration strategies.

**Patients and methods/Materials and methods:** It was a randomized cross-over monocentric study. Patients with moderate to severe COVID-19 associated ARDS were enrolled within 72 h after intubation. Patients were ventilated in volume-controlled ventilation (tidal volume=6 mL/kg predicted body weight). A decremental PEEP trial (PEEP from 20 to 5 cmH₂O by steps of 3 cmH₂O every 3 min) was performed in order to determine the PEEP levels associated with the lowest Global Inhomogeneity index with a plateau pressure lower than 30 cmH₂O (GI strategy) ii a percentage of collapsed lung tissue lower than 15% and the lowest hyperdistension percentage (OD-CL strategy) and iii with a plateau pressure between 28 and 30 cmH₂O (Express strategy). The PEEP level determined according to the three tested strategies was then applied in a randomized order (three periods of 45 min). Gas exchange, respiratory mechanics including airway and

esophageal pressure measurements, hemodynamic and gas distribution using EIT were assessed at the end of each period.

**Results:** Twenty patients have been included in the analysis. PEEP levels determined by the OD-CL strategy were lower than those determined by GI and Express strategies (median [interquartile range], 11 [8–14] cmH₂O, 20 [17–20] cmH₂O, 17 [15–18] cmH₂O, respectively, p < 0.001). PaO₂/FiO₂ ratio was higher with GI and Express strategies compared to OD-CL strategy (173 [133–224] mmHg, 158 [135–203] mmHg, 137 [113–172] respectively, p < 0.001). Respiratory system compliance and cardiac output (CO) did not differ between the three PEEP titration strategies. The expiratory transpulmonary pressure was ≤ 2 cmH₂O in seven patients (35%) with OD-CL strategy and three with Express and GI strategies (p = 0.2). The inspiratory transpulmonary pressure calculated according to the elastance ratio was > 22 cmH₂O in four patients with OD-CL strategy and five patients (25%) with Express and GI strategies (p = 0.9).

**Conclusion:** OD-CL strategy lead to lower PEEP levels than the Express and GI strategies. OD-CL strategy is associated with decreased oxygenation but similar respiratory mechanics and hemodynamic parameters.

**Compliance with ethics regulations:** Yes in clinical research.

**CO-71**
**Global Ventilation-Perfusion mismatch improvement related to PEEP increase in patients with highly recrutable lungs**

PAVLOVSKY Bertrand¹,², PESENTI Antonio², SPINELLI Elena², SCARAMUZZO Gaetano³, MARONGIÜ Ines², TAGLIABUE Paola², SPADARO Savino², GRASSELLI Giacomo², MERCAT Alain¹, MAURI Tommaso²
¹CHU Angers, Angers, France; ²Fundazione IRCCS Ca'Granda, Ospedale Maggiore Policlinico, Milan, Italie; ³Ospedale Universitario Sant'Anna, Ferrara, Italie

**Correspondence:** Bertrand PAVLOVSKY (bertrand.pavlovsky@gmail.com)

Annals of Intensive Care 2022, **12**(1):CO-71

**Rationale:** The Acute Respiratory Distress Syndrome (ARDS) is characterized by an important Ventilation-Perfusion (V/Q) mismatch. By recruiting the collapsed lung areas, Positive End Expiratory Pressure (PEEP) may enhance V/Q coupling, by decreasing shunt and allowing a redistribution of ventilation through perfused regions. We hypothesized that higher PEEP may improve V/Q mismatch in ARDS patients with highly recrutable lungs.

**Patients and methods/Materials and methods:** We enrolled fifteen patients with moderate or severe ARDS in this study, within 2 [2–5] days from intubation. Two PEEP levels (5 and 15 cmH₂O) were applied in a random order. Gas exchange and respiratory mechanics were assessed at each step. V/Q mismatch was evaluated by the Electrical Impedance Tomography (EIT) 5% NaCl bolus method at each PEEP level. Respective fractions of ventilation and perfusion across all V/Q ratios were built, leading to precise assessment of their distribution throughout different V/Q mismatch compartments. The amount of wasted ventilation and perfusion were computed according to this model as follows: sum of (log(V/Q) * V or Q), for all pixels in the functional EIT image within each ROI, including only units with V/Q ratio < 1 and > 1, respectively for wasted ventilation and wasted perfusion. Recruitment between the two PEEP levels was measured by the recruitment-to-inflation ratio (R/I) method.

**Results:** Median age was 60 [48–68] years, and body mass index 27.3 [25.7–35.4] kg.m⁻². Between PEEP 5 and 15 cmH₂O, PaO₂/FiO₂ increased from 125 [69–194] to 162 [90–198] mmHg (p = 0.011), while PaCO₂ decreased, albeit non significantly (49.8 [42.0–61.0] vs. 48.0 [42.0–52.1] mmHg, p = 0.403). Respiratory system compliance remained stable (36 [25–50] vs. 32 [24–42] mL.cmH₂O⁻¹, p = 0.164). Patients were characterized by an elevated lung recruitability (R/I ratio 1.29 [1.01–1.53]). In the global population V/Q mismatch improved, as shown by the mean distributions of ventilation and perfusion fractions (Figure, panel A). Both wasted ventilation (17 [14–20] vs. 14 [10–18] %, p = 0.109) and wasted perfusion (16 [13–22] vs. 14 [9–17] %, p = 0.005) decreased at higher PEEP levels. There was a correlation between the R/I ratio and the amount of decrease in both variables from PEEP 5 to 15 cmH₂O (Figure, Panel B and C).
**Conclusion:** In patients with highly recruitable lungs, V/Q mismatch is improved by higher PEEP levels. This effect is correlated with lung recruitability.

**Compliance with ethics regulations:** Yes in clinical research.

<figure><img src="image_33.png" /></figure>

Distribution of the fraction of ventilation (blue) and perfusion (red) across all V/Q ratios at PEEP 5 and 15 cmH₂O (A). Correlations between R/I ratio and the improvement in Wasted Ventilation (B) and Perfusion (C) between PEEP 5 and 15 cmH₂O.

CO-72

**Reconnection to mechanical ventilation for 1 h after a successful spontaneous breathing trial in ICU: Physiological effects on alveolar recruitment**

COUDROY Rémi¹, LEJARS Alice¹, RODRIGUEZ Maeva¹, ARRIVÉ François¹,
REYNAUD Faustine¹, BOISSIER Florence¹, VEINSTEIN Anne¹, CHATELLIER
Delphine¹, ROBERT René¹, FRAT Jean-Pierre¹, THILLE Arnaud W.¹

¹CHU de Poitiers, Poitiers, France **Correspondence:** Rémi COUDROY
(remi.coudroy@chu-poitiers.fr)

Annals of Intensive Care 2022, **12**(1):CO-72

**Rationale:** After a successful spontaneous breathing trial (SBT), reconnection to mechanical ventilation for 1 h is associated with lower reintubation rates than direct extubation1. However, physiological explanations leading to this clinical effect remain unclear. We hypothesized that reconnection to mechanical ventilation for 1 h after a successful SBT induces alveolar recruitment. Our primary aim was to compare end-expiratory lung volume (EELV) at the end of a successful SBT and 1 h after reconnection to mechanical ventilation.

**Patients and methods/Materials and methods:** This is an ancillary study of a multicenter randomized controlled trial comparing T-piece versus pressure-support (pressure support of 8 cmH₂O without positive end-expiratory pressure) for SBT before extubation. All patients included were at high-risk of extubation failure, i.e. intubated at least 24 h and older than 65 years or having underlying chronic cardiac or lung disease.2 In this physiological single-center study, EELV was measured using the nitrogen washin-washout technique before the SBT under mechanical ventilation, at the end of the SBT, and then 10 min, and 1 h after reconnection to mechanical ventilation. Regional ventilation using electrical impedance tomography was continuously recorded during the study. SBT was performed for around 1 h using T-piece or low pressure-support levels according to the randomization.

**Results:** From the 25 patients analyzed, 11 (44%) had SBTs performed using T-piece and 14 (56%) using pressure-support. Median age was 71 years [interquartile range 67–75] and duration of mechanical ventilation was 8 days [4–13]. All in all, median EELV was 1938 mL [IQR,

1370–2514] before SBT and decreased by 30% [95 CI, 23–37] at the end of the SBT (p < 0.001). The decrease in EELV at the end of the SBT was greater using T-piece than using pressure-support (decrease by 43% [95% CI, 35–51] vs. 20 [95% CI, 13–26], p < 0.001). EELV significantly re-increased from 1305 mL [IQR, 1074–1703] at the end of the SBT to 1927 mL [IQR, 1377–2470] after 1 h of reconnection to mechanical ventilation (mean difference of 587 mL [95% CI, 406–767], p < 0.001). After only 10 min of reconnection to mechanical ventilation, 101% [95% CI, 64–137] of this increased EELV had already been recovered. Regional ventilation was mainly distributed in the non-dependent lung regions and did not differ between T-piece and pressure-support.

**Conclusion:** SBT induced a marked alveolar derecruitment which was significantly greater after SBT using T-piece than using pressure-support. This lung volume loss was almost completely recovered after 10 min of reconnection to mechanical ventilation regardless the type of SBT.

**Reference 1:** Fernandez MM, González-Castro A, Magret M, Bouza MT, Ibañez M, García C, et al. Reconnection to mechanical ventilation for 1 h after a successful spontaneous breathing trial reduces reintubation in critically ill patients: a multicenter randomized control.

**Reference 2:** Thille AW, Coudroy R, Gacouin A, Ehrmann S, Contou D, Dangers L, et al. T-piece versus pressure-support ventilation for spontaneous breathing trials before extubation in patients at high risk of reintubation: protocol for a multicentre, randomised control.

**Compliance with ethics regulations:** Yes in clinical research.

CO-73

**Impact of extra-respiratory stimulations on dyspnea in critically ill mechanically ventilated patient—The sensopnea 2 study**

BUREAU Côme¹, NIÉRAT Marie-Cécile¹, DECAVÉLE Maxens¹, DANGERS
Laurence¹, CANTIER Marie¹, VIROLLE Sara¹, DELERIS Robin¹, DELEMAZURE
Julie¹, MAYAUX Julien¹, DRES Martin¹, SIMILOWSKI Thomas¹, DEMOULE
Alexandre¹

¹Hôpital Universitaire Pitié-Salpêtrière, Paris, France **Correspondence:** Côme BUREAU (come.bureau@aphp.fr)

Annals of Intensive Care 2022, **12**(1):CO-73

**Rationale:** Half of patients undergoing mechanical ventilation (MV) in the intensive care unit report a dyspnea of moderate to severe intensity, which causes immediate suffering and post-traumatic stress disorders. Dyspnea has two distinct components, a sensory component and an emotional component. Our objective was to evaluate and to compare the respective impact of a modulation of the sensory component (respiratory afferents) and the emotional component (extra respiratory auditory and sensory stimulations) on the intensity of dyspnea in critically ill patients undergoing MV, either invasive or non-invasive.

**Patients and methods/Materials and methods:** Patients MV for more than 48 h with a dyspnea intensity ≥ 40 mm on a visual analog dyspnea scale (Dyspnea-VAS) were included. We studied the following interventions: (1) increase of pressure support level by 5 cmH₂O vs. baseline ventilator settings as a control (sensory component), (2) a relaxing standardized music piece vs. a "pink" noise as a control (emotional component), and (3) fresh air directed toward the face vs. the thigh as a control (emotional component). A washout period separated each condition. Dyspnea was assessed with the Dyspnea-VAS and the A1 score of the Multidimensional Dyspnea Profile. The respiratory drive was assessed by the P0.1 and electromyographic activity of the Alea Nasi and parasternal muscles.

**Results:** We included 46 patients, 19 tracheostomized, 18 intubated and 9 under non-invasive ventilation. Median (interquartile range) age was 63 years (54–73) and duration of mechanical ventilation was 33 days (7–49). Compared to their respective control group the three intervention decreased Dyspnea-VAS: 1) pressure support increment 20 [20–40] mm vs. 70 [60–80], p < 0.0001, 2) auditory stimulation 40 [20–40] vs. 70 [60–80], p < 0.0001 and 3) sensory stimulation 40 [30–50] vs. 60 [50–80], p < 0.0001). Compared to their respective control group the three interventions decreased A1: 1) pressure support increment 5
[4–6] vs. 7 [6–8], p < 0.0001, 2) auditory stimulation 2 [0–2] vs. 7 [6–8], p < 0.0001 and 3) sensory stimulation 3 [2–4] vs. 7 [6–8], p < 0.0001. The electromyographic activity of Alea nasi and parasternal muscles decreased significantly after pressure support increment (p < 0.0001 for both) but did not change during auditory and sensory stimulation. P0.1 decreased more markedly with pressure support increment (3.7 [2.7–5.1] cmH₂O vs. 6.5 [6.0–8.1], p < 0.0001) than with auditory (6.0 [5.7–7.4] vs. 6.3 [6.0–7.7], p = 0.002) and sensory (6.0 [5.3–7.6] vs. 6.5 [5.7–7.7], p = 0.001) stimulation.

**Conclusion:** In critically ill MV patients, auditory and sensory extra-respiratory stimulations decreased dyspnea without decreasing respiratory drive, suggesting a mechanism involving a modulation of the emotional component.

**Compliance with ethics regulations:** Yes in clinical research.

## CO-74

### Accuracy of pulse oximetry (SpO₂) with different oximeters—Oxygap study

BLANCHET Marie-Anne<fnref n="1" />, MERCIER Gabriel<fnref n="1" />, DELOBEL Antoine<fnref n="1" />, NAYET Emi<fnref n="1" />, BOUCHARD Pierre-Alexandre<fnref n="1" />, LELLOUCHE François<fnref n="1" />

¹Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada

**Correspondence:** Marie-Anne BLANCHET (marie-anne.blanchet.2@ulaval.ca)

Annals of Intensive Care 2022, **12**(1):CO-74

**Rationale:** An accurate SpO₂ value is critical in order to optimally titrate the O₂ flow or FiO₂ delivered to patients under oxygen support and to follow oxygenation guidelines. It has been shown with closed-loop oxygen titration that small variations in SpO₂ target greatly affect the oxygen flow required, which may have a relevant impact on clinical decisions. However, the oximeters' accuracy appears to vary widely from model to model, leading to an underestimation or an overestimation of actual SaO₂ values. This variability may represent an obstacle to an optimal delivery of oxygen therapy, including the implementation of guidelines. The objective of this study was to assess the accuracy and bias of the SpO₂ value measured by several oximeters compared to the reference value, arterial oxygen saturation (SaO₂) measured by arterial gases in intubated and spontaneously breathing patients in the intensive care unit.

**Patients and methods/Materials and methods:** (ClinicalTrials.gov ID: NCT04772183) The study was approved by the local ethics board with a waiver of consent. We included stable patients hospitalized in the ICU with an arterial catheter in place. Main exclusion criteria were: respiratory instability, poor SpO₂ signal, infectious isolation, SpO₂ > 96%. We evaluated six oximeters: Nonin (Plymouth, MN), Masimo (Irvine, CA), Philips (Eindhoven, Netherlands), Nellcor (Pleasanton, CA), Fingers were randomized at each patient. Arterial blood gases were drawn and simultaneously, SpO₂ values for all oximeters were collected. SpO₂ value were compared to the reference (SaO₂ value) to determine bias and accuracy. The ability for oximeters to detect hypoxemia and the impact of oximeters on oxygen titration were evaluated.

**Results:** We included 210 patients (153 men; 57 women, mean age 66.3 ± 11.2 years). The skin pigmentation evaluated by Fitzpatrick showed 96.2% of patients were type 1 or 2. One oximeter overestimated SaO₂ (Philips, +0.9%) while the three others underestimated SaO₂ (Nonin – 3.1%, Nellcor – 0.3%, Masimo – 0.2%). Oxygen saturation was underestimated with Nonin oximeter in 91.3% of the cases while it was overestimated in 55.2% of the cases with Philips oximeter. Hypoxemia was detected in 100%, 26%, 37% and 11% of the cases with Nonin, Nellcor, Masimo and Philips respectively (Table 1).

**Conclusion:** We found large systematic and random errors between the tested oximeters and the arterial blood gases, in the studied population. These discrepancies may have important clinical impact on the detection of hypoxemia or management of oxygen.

**Compliance with ethics regulations:** Yes in clinical research

<table><thead><tr><th></th><th>SaO<sub>2</sub><br>(reference)</th><th>Nonin</th><th>Nellcor</th><th>Masimo</th><th>Philips</th></tr></thead><tbody><tr><td>O<sub>2</sub> saturation (%)<br>Mean±SD</td><td>93.6±2.2</td><td>90.5±2.8</td><td>93.3±2.3</td><td>93.4±2.4</td><td>94.5±2.4</td></tr><tr><td>Bias (SaO<sub>2</sub>–SpO<sub>2</sub>) (%)<br>Mean±SD</td><td>-</td><td>-3.1±2.1</td><td>-0.3±1.7</td><td>0.2±1.9</td><td>0.9±1.9</td></tr><tr><td>Overestimation<br>(% measurements)</td><td>-</td><td>3.9</td><td>28.2</td><td>30.8</td><td>55.2</td></tr><tr><td>Underestimation<br>(% measurements)</td><td>-</td><td>91.3</td><td>41.1</td><td>42.8</td><td>21.4</td></tr><tr><td>Detection of hypoxemia (%)<br>SaO<sub>2</sub> &lt; 90%<br>PaO<sub>2</sub> &lt; 60 mmHg<sup>1</sup></td><td>92<br>100</td><td>33<br>26</td><td>42<br>37</td><td>17<br>11</td><td></td></tr></tbody></table>

<caption>Table 1. Main features of evaluated oximeters. Mean, standard deviation, percentage of over and underestimation of the SaO₂ and detection of hypoxemia for tested oximeters.</caption>

## CO-75

### Effective FiO₂ delivered by a new frugal CPAP system with low oxygen requirements: first clinical observations

DE BEAUFORT Eloïse<fnref n="1" />,⁷,⁸, MORIN François², CARTEAUX Guillaume³,⁷,⁸, BOUJELBEN Mohamed²,⁷,⁸, BROC Alexandre<fnref n="1" />, LESIMPLE Arnaud<fnref n="1" />,⁹, TAILANTOU-CANDAU Mathilde², BIZOUARD Thomas², SAVARY Dominique²,⁴, MERCAT Alain², BELONCLE François², BROCHARD Laurent⁵,⁶, RICHARD Jean-Christophe<fnref n="1" />,², MEKONTSO-DESSAP Armand³,⁷,⁸

¹Air Liquide Medical Systems, Antony, France; ²Centre Hospitalier Angers, Angers, France; ³Centre Hospitalier Henri Mondor, Créteil, France; ⁴École des hautes études en santé publique, Rennes, France; ⁵St. Michael's Hospital, Toronto, Canada; ⁶Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; ⁷Institut Mondor de Recherche Biomédicale, Créteil, France; ⁸Université Paris-Est Créteil, Créteil, France; ⁹Institut MITOVASC, Angers, France

**Correspondence:** Eloïse DE BEAUFORT (eloise.debeaufort@airliquide.com)

Annals of Intensive Care 2022, **12**(1):CO-75

**Rationale:** In patients with COVID-19 related de novo acute respiratory failure, the application of continuous positive airway pressure (CPAP) improves respiratory mechanics, gas exchange and outcome [1]. In the context of a pandemic with a massive influx of hypoxemic patients, the high oxygen consumption required to achieve optimal inspired oxygen (FiO₂) may jeopardize health care organization and oxygen delivery hospital capabilities. Within the framework of frugal innovation [2], we have designed a new Bag-CPAP device aiming at meeting oxygen delivery constraints. The aim of these clinical observations was to evaluate the performances of the Bag-CPAP in terms of FiO₂ actually delivered, oxygen consumption, airway pressure and clinical tolerance.

**Patients and methods/Materials and methods:** The Bag-CPAP is intended to deliver a positive end expiratory pressure (PEEP of 5–10 cmH₂O) with two levels of FiO₂: moderate (50%–60%) or high (90%–100%) obtained with an oxygen flow rate of 5 and 15 L/min, respectively. The system operates with a 30L reservoir for gas accumulation to reduce oxygen consumption and guarantee FiO₂ irrespective of respiratory demand.

After ANSM authorization, the clinical observation was conducted in two university hospitals in France, on 20 adult patients with de novo acute respiratory failure. PEEP level was adjusted at 7.5 cmH₂O in all patients and FiO₂ (moderate or high) was selected according to patients' needs. Actual FiO₂ and PEEP were regularly measured along with respiratory pattern and dyspnea score. Quantitative data are expressed as median [interquartile range], a P value < 0.05 was considered statistically significant.

**Results:** Median FiO₂ were 53% [52%–53%] for moderate FiO₂ target and 94% [93%–96%] for high FiO₂ target with an oxygen flow rate of 8 [7–9] L/min and 15 [15–16] L/min respectively (Fig. 1). 98% of FiO₂

<footnote n="1">¹Based on 9 patients for SaO₂ < 90% and 16 patients for PaO₂ > 60 mmHg</footnote>
values were within the expected target ranges for both moderate and high $FiO_2$. Median PEEP was 7 [5–7] cmH₂O. $SpO_2$ significantly increased and Borg dyspnea Scale significantly decreased since the first hour of Bag-CPAP application (93% [90%–97%] vs. 97% [95%–98%]), $p$ = 0.001 and 4 [2–7] vs. 3 [2–4], $p$ = 0.017, respectively). No significant effect was observed on respiratory rate.

**Conclusion:** This pilot clinical experience shows that the Bag-CPAP is well tolerated while allowing reaching high $FiO_2$ with low oxygen consumption: greater than 50% and 90% with an oxygen flow rate of at least 5 [5 to 10] L/min and 15 [10 to 20] L/min respectively.

**Reference 1:** G. D. Perkins et al., « An adaptive randomized controlled trial of non-invasive respiratory strategies in acute respiratory failure patients with COVID-19», août 2021. https://doi.org/10.1101/2021.08.02.21261379.

**Reference 2:** A. Mekontso Dessap, « Frugal innovation for critical care», Intensive Care Med., vol. 45, no 2, p. 252?254, févr. 2019, https://doi.org/10.1007/s00134-018-5391-6.

**Compliance with ethics regulations:** Yes in clinical research.

<figure><img src="image_34.png" /></figure>

FiO₂ measurements according to oxygen flow rate during Bag-CPAP treatment and FiO₂ target range (moderate: green or high: pink)

## CO-76

### Comparison of positive end-expiratory pressure titration strategies based on measured end-expiratory transpulmonary pressure and calculated end-inspiratory transpulmonary pressure in acute respiratory distress syndrome: a physiological study

CHEAN Dara¹, COURTAIS Antonin¹, PAVLOVSKY Bertrand¹, YVIN Elise¹, DESPREZ Christophe¹, TAILANTOU-CANDAU Mathilde¹, RICHARD Jean-Christophe¹, MERCAT Alain¹, BELONCLE François¹
¹CHU ANGERS, Angers, France

**Correspondence:** Dara CHEAN (dara.chean@gmail.com)

Annals of Intensive Care 2022, **12**(1):CO-76

**Rationale:** The optimal positive end-expiratory pressure (PEEP) titration strategy for patients with acute respiratory distress syndrome (ARDS) is still a matter of debate. Esophageal pressure monitoring allows to estimate pleural and transpulmonary pressures. Two distinct strategies based on measured end-expiratory transpulmonary pressure ($P_{L, exp}$) or calculated end-inspiratory transpulmonary pressure ($P_{L, insp calc}$) have been described but their physiological effects have never been compared to each other. This study aimed at comparing the short-term ventilatory and hemodynamic effects of these two strategies in patients with ARDS.

**Patients and methods/Materials and methods:** $P_{L, exp}$ was computed as the difference between total PEEP and esophageal pressure measured at end-expiration. In $P_{L, exp}$-based PEEP titration strategy, PEEP was set to maintain $P_{L, exp}$ between 0 and 6 cmH₂O using a $P_{L, exp}$-$FiO_2$ table¹. In $P_{L, insp calc}$-based PEEP titration strategy, $P_{L, insp calc}$ was estimated using the lung to respiratory system elastance ratio and PEEP was set to achieve a $P_{L, insp calc}$ between 20 and 22 cmH₂O². $P_{L, exp}$-based and $P_{L, insp calc}$-based strategies were consecutively applied in a randomized order in patients with moderate to severe ARDS.

Gas exchange, respiratory mechanics, hemodynamics and ventilation regional distribution assessed with electrical impedance tomography were evaluated 45 min after the application of each PEEP titration strategy.

**Results:** Twenty patients were included in this study. Twelve (60%) patients had SARS-CoV2 associated pneumonia. The two different PEEP titration strategies led to similar median levels of PEEP (median [interquartile range], 14 [9–17] cmH₂O with $P_{L, exp}$-based strategy vs 16 [12–18] cmH₂O with $P_{L, insp calc}$-based strategy, $p$ = 0.11) but 14 (70%) patients presented a difference of at least 3 cmH₂O between the two determined PEEP levels. $PaO_2/FiO_2$, shunt fraction, dead-space, cardiac index and oxygen delivery were similar between the two strategies. The 12 (60%) patients for whom $P_{L, insp calc}$-based strategy was associated with higher PEEP levels than $P_{L, exp}$-based strategy were characterized by a lower body mass index. Compared to $P_{L, exp}$-based strategy, $P_{L, insp calc}$-based strategy was associated, in these patients, with better oxygenation but lower cardiac output, higher transpulmonary driving pressure, lower respiratory system compliance and lower non-dependant regional compliance, suggesting lung overdistension.

**Conclusion:** PEEP levels defined by the two distinct esophageal pressure measurements-based strategies differed of at least 3 cmH₂O in 70% of ARDS patients. $P_{L, insp calc}$-based strategy may be associated with lung overdistension in some patients.

**Reference 1:** Talmor, D. et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. N. Engl. J. Med. 359, 2095–2104 (2008).

**Reference 2:** Grasso, S. et al. ECMO criteria for influenza A (H1N1)-associated ARDS: role of transpulmonary pressure. Intensive Care Med 38, 395–403 (2012).

**Compliance with ethics regulations:** Yes in clinical research.

## CO-77

### Respiratory effects of lung recruitment maneuvers depend on the recruitment-to-inflation ratio

ZERBIB Yoann¹, LAMBOUR Alexis¹, MAIZEL Julien¹, KONTAR Loay¹, DE CAGNY Bertrand¹, SOUPISON Thierry¹, BRADIER Thomas¹, SLAMA Michel¹, BRAULT Clément¹

¹CHU Amiens-Picardie, Amiens, France Correspondence: Clément BRAULT (brault.clement@chu-amiens.fr)

Annals of Intensive Care 2022, **12**(1):CO-77

**Rationale:** In the context of acute respiratory distress syndrome (ARDS), the response to lung recruitment maneuvers (LRM) varies considerably from one patient to another. The LRM can be harmful, especially in patients with low recruitability, inducing lung overdistention and cardiac dysfunction. Recently, a single-breath maneuver with measurement of the recruitment-to-inflation (R/I) ratio has been developed to assess lung recruitability and identify patients who could benefit from the application of positive pressure. Here, we determined whether or not the R/I ratio could differentiate between patients according to the change in lung mechanics during LRM.

**Patients and methods/Materials and methods:** We included all adults patients admitted with a diagnosis of ARDS and an arterial oxygen partial pressure to fractional inspired oxygen ($PaO_2/FiO_2$) ratio lower than 150 mmHg. Starting at 20 cmH₂O, the PEEP was increased in 5 cmH₂O steps to 40 cmH₂O, with each step lasting 2 min. We evaluated the changes in gas exchange, respiratory mechanics, and hemodynamic parameters induced by a stepwise LRM at a constant driving pressure of 15 cmH₂O during pressure-controlled ventilation. Patients were dichotomized with regard to the median R/I ratio.

**Results:** We included 30 patients with a median [interquartile range] R/I ratio of 0.62 [0.42-0.83]. The $PaO_2/FiO_2$ ratio increased significantly after LRM in patients with low and high lung recruitability (Table 1). However, the mechanisms behind this improvement in oxygenation depend on each patient's potential for alveolar recruitment, as measured by the R/I ratio. In patients with high recruitability (R/I ratio ≥ 0.62), the static respiratory system compliance (CrS) increased significantly after the LRM (33 [27–42] vs. 42 [35–60] mL/cmH₂O; $p$ < 0.001). There was a moderate but significant positive correlation between the change in CrS during the LRM and the R/I ratio ($r$ = 0.56;
p=0.001). In patients with low recruitability (R/I ratio <0.62), the increase in PaO₂/FiO₂ ratio was associated with a significant decrease in pulse pressure (70 [55–85] vs. 50 [51–67] mmHg; p=0.01) but not with a significant change in Crs (33 [24–47] vs. 35 [25–47] mL/cmH₂O; p=0.74).

**Conclusion:** During an LRM, the mechanisms related to an increase in oxygenation depend on the potential for lung recruitment. Patients with high recruitability presented a significant increase in Crs (indicating a gain in ventilated area), while those with low recruitability presented a decrease in pulse pressure suggesting a drop in cardiac output and therefore in intrapulmonary shunt. The R/I ratio might help clinicians to identify patients in whom an LRM will lead to an increase in Crs.

**Compliance with ethics regulations:** Yes in clinical research.

<table><thead><tr><th rowspan="2">Parameters</th><th colspan="3">R<sub>I</sub> < 0.62</th><th colspan="3">R<sub>I</sub> ≥ 0.62</th></tr><tr><th colspan="3">n=15</th><th colspan="3">n=15</th></tr><tr><th></th><th>Pre-LRM</th><th>Post-LRM</th><th>p value</th><th>Pre-LRM</th><th>Post-LRM</th><th>p value</th></tr></thead><tbody><tr><td>P<sub>O₂</sub>/F<sub>O₂</sub> mmHg</td><td>106 [101–132]</td><td>186 [128–192]</td><td>0.01</td><td>99 [73–131]</td><td>106 [98–151]</td><td>0.05</td></tr><tr><td>C<sub>m</sub> mL/cmH₂O</td><td>33 [24–47]</td><td>35 [25–47]</td><td>0.74</td><td>33 [27–42]</td><td>42 [35–60]</td><td>&lt;0.001</td></tr><tr><td>P<sub>ex</sub> cmH₂O</td><td>-2 [-6–2]</td><td>2 [-1–5]</td><td>&lt;0.001</td><td>-4 [-6–2]</td><td>1 [-2–3]</td><td>&lt;0.001</td></tr><tr><td>P<sub>ex</sub> cmH₂O</td><td>12 [9–17]</td><td>14 [10–17]</td><td>&gt;0.99</td><td>15 [11–18]</td><td>16 [11–19]</td><td>0.96</td></tr><tr><td>PP mmHg</td><td>70 [55–85]</td><td>50 [51–67]</td><td>0.01</td><td>61 [43–70]</td><td>54 [46–70]</td><td>0.51</td></tr><tr><td>HR beats/min</td><td>96 [73–105]</td><td>92 [68–112]</td><td>0.56</td><td>80 [68–105]</td><td>88 [64–96]</td><td>0.74</td></tr></tbody></table>

Respiratory and hemodynamic parameters before and after the LRM, as a function of the patients' lung recruitability

## CO-78

### Chest electrical impedance tomography and lung ultrasound to monitor extubation

JOUSSELLIN Vincent¹,², JANIAK Vincent³,⁴, BONNY Vincent¹,², CLERC Sébastien¹, MAYAUX Julien¹, MORAWIEC Elise¹, TALLEC Gwendolyne⁴, SALEEM Umar⁴, PINNA Andrea³, DRES Martin¹,²

¹AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive – Réanimation (Département "R3S"), Paris, France;

²Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France; ³Sorbonne Université, CNRS, LIP6, Paris, France; ⁴Bioserenity, Paris, France

**Correspondence:** Vincent JOUSSELLIN (vincent.joussellin@gmail.com)

Annals of Intensive Care 2022, **12**(1):CO-78

**Rationale:** Chest Electrical Impedance Tomography (EIT) is a non-invasive technique that produces continuous cross-sectional images of regional lung ventilation. This study investigated the use of chest EIT and lung ultrasound in patients extubated after a successful spontaneous breathing trial. The hypothesis was that patients with extubation failure may exhibit early regional lung ventilation disturbances and higher lung ultrasound score (LUS) as compared to patients with extubation success.

**Patients and methods/Materials and methods:** Patients at high risk of extubation failure (>65 years old, chronic cardiac or pulmonary disease) were included after a successful spontaneous breathing trail and after extubation was planned by the physicians. Lung ultrasound (with calculation of LUS score as a surrogate of loss of lung aeration) and chest EIT (with calculation of derived indices, such as Global inhomogeneity index (GI), front-back Centre of ventilation (CoV), Regional ventilation delay (RVD) and Surface available for ventilation) were performed before (H0) and two hours and six hours after extubation (H2 and H6 respectively). The primary outcome was the proportion of patients who presented extubation failure (defined as acute respiratory failure requiring re-intubation or not or death within 48 h after extubation).

**Results:** Thirty-four patients were included, of whom 10 (29%) were considered with extubation failure. Before extubation, the LUS score was higher in the extubation failure group as compared to patients who were successfully extubated (20 vs 11, p<0.01). However, EIT derived indices were not different between groups. After extubation, GI index, RVD and LUS score were higher in the extubation failure group, whereas Surface was lower and the CoV didn't change (See an example in Fig. 1).

**Conclusion:** Before extubation, a loss of lung aeration was observed in patients who developed extubation failure afterwards. After extubation, this loss persisted with adjunction of heterogeneity in air distribution observed with EIT.

**Compliance with ethics regulations:** Yes in clinical research.

<figure><img src="image_35.png" /></figure>

EIT derived indices in a patient who presented extubation failure 24 h after extubation compared to a patient who were successfully extubated GI index: Global inhomogeneity index; RVD: Regional ventilation delay; H0: just before extubation; H2 and H6:

## CO-79

### Clinical and microbiological features of drowning associated pneumonia: a multicenter cohort study

REIZINE Florian¹, AGATHE Delbove², DOS SANTOS Alexandre³, BODENES Laetitia⁴, BOUJU Pierre⁵, FILLÂTRE Pierre⁶, FRÉROU Aurélien⁷, HALLEY Guillaume⁸, LESIEUR Olivier⁹, COUROUBLE Patricia¹⁰, BERTEAU Florian¹¹, MORIN Jean¹², DELAMAIRE Flora¹, MARNAI Rémy¹³, LE MEUR Anthony¹⁴, AUBRON Cécile⁴, REIGNIER Jean¹², GACOUIN Arnaud¹, TADIÉ Jean-Marc¹
¹CHU de Rennes, Rennes, France; ²CH Vannes, Vannes, France; ³CH La Roche sur Yon, La Roche Sur Yon, France; ⁴CHU Brest, Brest, France; ⁵CH Lorient, Lorient, France; ⁶CH Saint Brieuc, Saint Brieuc, France; ⁷CH Saint Malo, Saint Malo, France; ⁸CH Quimper, Quimper, France; ⁹CH La Rochelle, La Rochelle, France; ¹⁰CH Saint Nazaire, Saint Nazaire, France; ¹¹CH Morlaix, Morlaix, France; ¹²CHU Nantes, Nantes, France; ¹³CH Le Mans, Le Mans, France; ¹⁴CH Cholet, Cholet, France

**Correspondence:** Florian REIZINE (florian.reizine@gmail.com)

Annals of Intensive Care 2022, **12**(1):CO-79

**Rationale:** Pneumonia is the most frequent infectious complication among drowning patients requiring ICU admission. However, clinical and microbiological data on such pneumonia are scarce.

**Patients and methods/Materials and methods:** We conducted a retrospective multicenter study (2013–2020) of 270 consecutive patients admitted for drowning to 14 ICUs in the west of France. Baseline characteristics as well as clinical course of patients were compared according to the occurrence of drowning associated pneumonia (DAP) (diagnosed within 48 h of ICU admission). Pneumonia microbiological features and therapeutic strategies were also analyzed.

**Results:** Among the 270 patients admitted to the ICUs for drowning, 101 (37.4%) experienced pneumonia. Suicidal etiology of drowning, psychiatric comorbidities, and need for mechanical ventilation appeared to be risk factors for drowning associated pneumonia (DAP). DAP occurred less frequently in patients initially treated by antibiotics. Pneumonia occurrence was associated with higher severity scores at ICU admission (Median SAPS 2 score 34 [Interg quartile range 25–55] versus 45 [28–67]; p=0.006), longer ICU LOS (2 days [1–3] versus 4 [2–7]; p<0.001), mechanical ventilation duration (2 days [1–4] versus 4.5 days [2–8]; p<0.001), higher SOFA score at day 3 (1 [0–3] versus 5 [1–10]; p=0.001) These patients also experienced acute respiratory distress syndrome (ARDS) more frequently (28.4% versus 53.5%; p<0.001). Survival at day-28 appeared lower among these patients particularly in patients developing microbiologically proven pneumonia (14/33 versus 201/237; p<0.0001). Interestingly, microbiological analysis of respiratory samples showed a high proportion of
gram-negative bacilli (39.6%) that did not differ according to water salinity. Empirical antimicrobial management seemed frequently inappropriate (30.3%) mostly due to high proportions of resistance to Amoxicillin-Clavulanate on isolates (39.4%).

**Conclusion:** Pneumonia occurrence was found to be a common com-
plication in critical drowning patients that worsen patients' clinical
courses. Due to a high proportion of resistant gram-negative bacilli
among isolated pathogens, initial empirical antimicrobial strategy
with Amoxicillin-Clavulanate should be discouraged.

**Compliance with ethics regulations:** Yes in clinical research.

CO-80

Prognosis of adult patients hospitalized with respiratory syncytial
virus infection: a multicenter retrospective observational cohort
study

CELANTE Héloïse<fnref n="1" />, OUBAYA Nadia<fnref n="1" />, LAYESE Richard<fnref n="1" />, DE PROST Nicolas<fnref n="1" />

¹Hôpital Henri-Mondor, Creteil, France

**Correspondence:** Héloïse CELANTE (heloise.celante@aphp.fr)

Annals of Intensive Care 2022, **12**(1):CO-80

**Rationale:** Respiratory syncytial virus (RSV) is a common agent of viral respiratory infections. It causes significant morbidity and mortality in adults, especially in those with cardiorespiratory comorbidities and immunosuppression. Although there is a high burden of RSV respiratory infections in frail adults, few data are available in hospitalized patients. We set up a retrospective multicenter cohort to obtain large-scale data aiming at better depicting the clinical profile and prognosis of patients hospitalized with RSV infection.

**Patients and methods/Materials and methods:** Retrospective multicenter observational cohort study conducted in all Assistance Publique-Hôpitaux de Paris (AP-HP) hospitals, including patients hospitalized between January 1, 2015 and December 31, 2019 for documented respiratory RSV infection. Data were extracted from the AP-HP Health Data Warehouse (EDS). The selection of patients and the procedures performed in intensive care units (ICUs, n = 13) were identified using International Classification of Disease (ICD) 10 and CCAM (Classification Commune des Actes Médicaux) coding. The primary endpoint was in-hospital mortality.

**Results:** 1168 patients were hospitalized for RSV infection, including 880 patients admitted to 14 conventional inpatient units and 288 patients who required ICU admission. The median age of patients was 75 years, 54% of them were women. Patients frequently had comorbidities, most often cardiovascular (hypertension: 46.4%; heart failure: 34.4%), respiratory (28.6%), or immunodepression (29.5%). In-hospital mortality was 6.6% (n=77/1168) in the whole cohort and 12.8% (n=37/288) in ICU patients. By multivariable logistic regression, the factors associated with hospital mortality were age (adjusted odds ratio (aOR)=1.03 95% CI [1.01–1.06], p=0.006), presence of an acute respiratory failure at ICU admission (aOR=2.35 [1.30–4.25], p=0.04), acute respiratory distress syndrome (aOR=6.49 [2.96–14.21], p<0,001) and neutropenia (aOR=5.57 [1.54–20.19], p=0,009). 30% of patients admitted to the ICU required invasive mechanical ventilation support. Risk factors for intubation were age (aOR=0.98 [0.96–0.99], p=0.002), a previous chronic respiratory failure (aOR=2.83 [1.72–4.65], p<0,001), chronic heart disease (aOR=1.90 [1.15–3.13], p=0.012), obesity (aOR=1.94 [1.09–3.45], p=0.025) and the documentation of a bacterial co-infection (aOR=2.51 [1.55–4.07], p<0.001). A bacterial co-infection was documented in 18.2% of patients. Streptococcus pneumoniae and Pseudomonas aeruginoswere the two most frequently isolated bacteria.

**Conclusion:** In this large multicenter retrospective study of patients hospitalized with RSV infection, we found a mortality rate of 6.6%. Risk factors associated with mortality were age, the presence of acute respiratory distress, ARDS and neutropenia.

**Compliance with ethics regulations:** N/A.

CO-81

Differences in clinical characteristics and outcomes
between Covid-19 and influenza in critically ill adult patients:
a national database study

NAOURI Diane⁶, PHAM Tai<fnref n="2" />, DEMOULE Alexandre<fnref n="2" />, MERCAT Alain⁵,
BEDUNEAU Gaetan³, COMBES Alain<fnref n="2" />, KIMMOUN Antoine⁴, SCHMIDT

Matthieu<fnref n="2" />, DRES Martin<fnref n="2" />, JAMME Matthieu<fnref n="1" />

¹Hôpital privé de l'ouest parisien, Trappes, France; ²Assistance publique hopitaux de Paris, Paris, France; ³CHU Rouen, Rouen, France; ⁴CHU Nancy, Nancy, France; ⁵CHU Angers, Angers, France; ⁶Direction de la recherche, des études, de l'évaluation et des statistiques, Paris, France

**Correspondence:** Matthieu JAMME (mat.jamme@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-81

**Rationale:** Until March 2020 and the emergence of coronavirus disease 2019 (COVID-19), influenza was the leading cause of viral acute respiratory failure observed in ICU. While a few studies have compared flu patients vs. COVID-19, none of them have focused on the most severe forms. The aim of this study is to compare ICU patients admitted for COVID-19 vs. those admitted with influenza.

**Patients and methods/Materials and methods:** We conducted a retrospective cohort study using the French administrative health database (Système National des Données de Santé, SNDS). We included all adult patients hospitalised in French ICUs for whom a complete hospital history was available from 1 March 2020 to 30 June 2021. For the comparative group (influenza cohort), all adult patients hospitalised in ICUs from 1 January 2014 to 31 December 2019 were included. To be included in one of these two groups, the patient had to have an ICD-10 diagnosis code of COVID-19 or influenza regardless of its position in the hospital stay summary. The Chi-square test, Student's t test or Wilcoxon test were used, as appropriate, to compare characteristics between patients with COVID-19 and influenza. To identify risk factors for invasive mechanical ventilation (IMV) and in-hospital death, we performed multivariate logistic regression models.

**Results:** Our study cohort included 105.979 COVID-19 patients and 18.763 influenza patients. Compared to influenza patients, COVID-19 patients were younger (p < 0.0001), more often male (p < 0.0001), and had a lower SAPS II score at ICU admission (p < 0.0001). During the ICU stay, patients with influenza more frequently required the use of iMV (47% versus 34%, p < 0.001), vasopressors (40% versus 27%, p < 0.001) and renal replacement therapy (22% versus 7%, p < 0.001). In-hospital mortality was higher in COVID-19 patients (25% vs. 21%, p < 0.001), especially in patients with iMV (40% vs. 33%, p < 0.001). After adjustment, while we did not observe an association between virus type and iMV use, we found a strong association between COVID-19 and in-hospital mortality compared to influenza (aOR=1.92 [1.83–2.00], p < 0.001).

**Discussion:**

**Conclusion:** Using a very large cohort study, patients admitted for COVID-19 have a high probability of in-hospital death compared to patients admitted for influenza. This excess mortality does not appear to be related to a higher proportion of organ failure, particularly with respect to iMV use.

**Compliance with ethics regulations:** Yes in clinical research.

CO-82

Lung microbiome in critical care: evolution and risk factors of VAP

FROMENTIN Mélanie<fnref n="1" />,<fnref n="2" />, MULLAERT Jimmy<fnref n="2" />, BRIDIER-NAHMIAS Antoine<fnref n="2" />,
MERCIER-DELARUE Séverine⁴, VUILLARD Constance<fnref n="2" />, DO VALE Julien<fnref n="2" />,
SALMONA Maud⁴, LE GOFF Jerome⁴, RICARD Jean-Damien<fnref n="2" />,³, ROUX
Damien<fnref n="2" />,³

<footnote n="1">¹Ramsay Santé, Hôpital privé Paul d'Égine, Champigny-Sur-Marne, France;</footnote>

<footnote n="2">²Université de Paris, INSERM, U 1137 IAME Infection Antimicrobials Modeling Evolution, Paris, France; ³AP_HP, Hôpital universitaire Louis Mourier,</footnote>
Colombes, France; ⁴Université de Paris, INSERM, U 976, HIPI Human Immunology, Pathophysiology & Immunotherapy, Paris, France

**Correspondence:** Mélanie FROMENTIN (mfromentin.anesthesierea@gmail.com)

Annals of Intensive Care 2022, **12**(1):CO-82

**Rationale:** We aimed to characterize and compare the temporal changes of lung bacterial microbiome whether ICU patients develop ventilator-associated pneumonia (VAP) or not. Our main objective was to identify early specific bacterial markers in the airway microbiome associated with the risk of ventilator-associated pneumonia (VAP) occurrence.

**Patients and methods/Materials and methods:** We conducted a case-control study based on a prospective cohort of mechanically ventilated (MV) patients. Controls were matched to VAP patients according to known risk factors of lung microbiota changes. We sequenced the specific V4 hypervariable region of 16S rRNA gene in samples collected every 72 h from oropharynx (OPS = oropharyngeal swabs) and lungs (ETA = endotracheal aspiration). The co-evolution of lung and oropharyngeal microbiota were described using non-linear mixed effects models.

**Results:** Nineteen VAP patients and 19 matched controls were included. We identified 281 taxa or operational taxonomic unit in 293 samples distributed in four predominant phyla. The dynamic evolution of the lung microbiota highlighted a constant increase in relative abundance of *Bacteroidetes* whereas these of *Firmicutes* decreased under mechanical ventilation (MV) (Fig. 1). On ICU admission, the *Bacteroidetes* phylum (p = 0.017) and the *Bacteroidia* class (p = 0.018) were more represented in patients who eventually developed a VAP. For all patients, the dynamic study highlighted a highly significant positive correlation between changes in lung and oropharyngeal microbiota for diversity (r = 0.87 (0.42;1), p < 0.001), for relative abundance of *Bacilli* (r = 0.91 (0.77;1), p < 0.001) and for relative abundance of *Bacteroidia* (r = 0.99 (0.94;1), p < 0.001). There was a significant decrease of the alpha diversity in both OPS (p < 0.001) and ETA during MV (p = 0.006), and a significant decrease of relative abundance of *Bacilli* in ETA (p < 0.001). On average, the relative abundance of *Bacteroidia* in the lungs was increased by an additional 14% per day of MV in VAP patients compared to controls (p = 0.025). The RA of *Bacilli* in the oropharynx decreased by an additional 9% per day of MV in VAP patients compared to controls (p = 0.049).

**Conclusion:** A lower initial RA of Bacteroidia, a faster decrease of Bacilli within the oropharynx as well as a faster increase of Bacteroidia within the lungs were associated with VAP development. This could represent a dysbiosis pattern that predisposed ICU patients to VAP. We aimed to characterize and compare the temporal changes of lung bacterial microbiome whether ICU patients develop ventilator-associated pneumonia (VAP) or not.

**Compliance with ethics regulations:** Yes in clinical research.

<figure><img src="image_36.png" /><figcaption>Evolution of relative abundance of the four main phyla identified in the respiratory microbiota</figcaption></figure>

## CO-83

### Involvement of lung epithelium in sepsis-induced immunosuppression

MALHERBE Jolan¹, LADJEMI Maha Zohra¹, ROUSSEAU Christophe¹, PÉJU Edwige¹,², LLITJOS Jean-François¹, BOULANT Léa¹, MARTIN Clémence¹,³, BURGEL Pierre-Régis¹,³, PÉNE Frédéric¹,²

¹Institut Cochin, Inserm U1016, CNRS UMR8104, Université de Paris, Paris, France; ²Service de Médecine intensive & Réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France; ³Service de Pneumologie & Centre National de Référence Mucoviscidose, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France

**Correspondence:** Jolan MALHERBE (jolan.malherbe@gmail.com)

Annals of Intensive Care 2022, **12**(1):CO-83

**Rationale:** Ventilator-associated pneumonia accounts for a leading cause of death in patients with septic shock. Altered lung immunity in post-septic hosts has been consistently ascribed to both quantitative and functional defects in most hematopoietic immune cells. In contrast, the role of airway epithelium has not been investigated in this setting despite its key role in first-line lung defense through various functions of physical barrier, tissue repair, pathogen sensing and crosstalk with immune cells. We raised the hypothesis that sepsis-induced alterations in airway epithelium contribute to defective lung defense towards secondary bacterial pneumonia. Our main goal was to assess the morphological and functional alterations of airway epithelium following non-pulmonary polymicrobial sepsis.

**Patients and methods/Materials and methods:** C57BL/6J female mice were used for the experiments. Mice were subjected to double-hit infectious insults through polymicrobial peritonitis induced by cecal ligation and puncture (CLP) or control sham surgery, followed eight days after by intratracheal instillation of *Pseudomonas aeruginosa*. The morphology and functions of lung epithelium were studied by immunohistochemistry and flow cytometry on days 3 and 7 after surgery, prior to any secondary bacterial challenge.

**Results:** As compared to sham-operated controls, post-CLP mice exhibited increased mortality towards secondary *P. aeruginosa* pneumonia, associated with increased systemic spread of the pathogen. Lung sections from post-CLP and sham-operated mice were subjected to histological analyses. Post-CLP mice exhibited reduced thickness of bronchial epithelium on day 3, associated with decreased proliferative capacity (as assessed by Ki67 immunostaining). However, bronchial epithelium became hypertrophied in post-CLP mice at delayed time point (day 7), thereby suggesting altered tissue repair. Tissue barrier functions were also altered as suggested by reduced epithelial expression of tight and adherens junctions (as assessed by *Zonula occludens* 1 and E-cadherin immunostainings). Increased expression of immune checkpoint inhibitors (day 3 post-sepsis) and Toll-like receptors 2 and 5 (day 7) were also observed in bronchial and alveolar epithelial cells from post-septic mice.

**Conclusion:** Our results suggest that non-pulmonary sepsis may modulate the main functions of airway epithelial cells and may thereby impact on lung compartmentalization. How this may affect mucosal immunity, possibly in relation with local dysbiosis, should now be investigated.

**Compliance with ethics regulations:** Yes in animal testing.

## CO-84

### Risk factors and outcomes of recurrent ventilator associated pneumonia in COVID-19 patients: a retrospective multicentric study

GRAGUEB CHATTI Ines¹, HYVERNAT Herve², LOPEZ Alexandre¹, AGARD Geoffray¹, PAPAZIAN Laurent¹, DELLAMONICA Jean², LEONE Marc¹, HRAIECH Sami¹

¹APHM, Marseille, France; ²CHU L'Archet, Nice, France

**Correspondence:** Sami HRAIECH (sami.hraiech@ap-hm.fr)

Annals of Intensive Care 2022, **12**(1):CO-84
**Rationale:** High incidence of ventilator associated pneumonia (VAP) has been reported among critically ill patients with COVID-19. Among these patients, we aimed to specifically assess the frequency, risk factors and outcomes of recurrences of VAP.

**Patients and methods/Materials and methods:** We conducted an observational retrospective study in 3 French intensive care units (ICUs). Patients admitted for a documented COVID-19 from March 2020 to May 2021 and requiring mechanical ventilation (MV) for ≥ 48 h were included. The study main outcome was the rate of VAP recurrence. Secondary outcomes were the risk factors for recurrence, the Day-28 and Day-60 ventilator-free days (VFD), the ICU and hospital length of stay and the Day-90 mortality.

**Results:** From 26th February 2020 to 21th May 2021, 398 patients were included in the analysis. Among them, 236 (59%) presented at least one VAP and 109 (27%) presented more than one VAP during the ICU stay (VAP recurrence). The overall ICU mortality rate was 27.9%, and day-90 mortality was 28.6%. After 90 days follow-up, the day-90 mortality rate of patients without VAP was significatively lower than mortality of patients with one VAP or more (p = 0.021). In contrast, there was no day-90 mortality difference between patients with one VAP or more than one (recurrence) (36.2% vs 31.2%). Patients with VAP recurrence had a longer duration of mechanical ventilation, less VFD at day-28 and day-60, a longer ICU and hospital length of stay. In multivariate analysis, a bacterial co-infection at ICU admission, the use of dexamethasone, the association of 2 immunosuppressive therapies or more during the ICU stay, the duration of antibiotic therapy, the type of bacteria responsible for the 1st occurrence of VAP were not significantly associated with VAP recurrence.

**Conclusion:** VAP recurrences are frequent among COVID-19 ICU patients and are associated with a longer MV duration, ICU and hospital length of stay but not a higher mortality as compared with patients that had only one VAP. Bacterial co-infection at ICU admission, the use of dexamethasone, the association of 2 immunosuppressive therapies or more during the ICU stay, the duration of antibiotic therapy or the type of bacteria responsible for the 1st occurrence of VAP were not identified as independent risk factors of VAP recurrence in our cohort.

**Compliance with ethics regulations:** Yes in clinical research.

## CO-85

**Severe acute kidney injury in severe SARS COV2: "For a time they are a-changin'" For the Kidney Injury Working Initiative in Critically ill eurOpean patients during Coronavirus Outbreak (KIWI COCO)**

CHAÎBI Khalil<fnref n="1" />, LOUIS Guillaume⁴, BOUBAYA Marouane<fnref n="1" />, BONNET Nicolas<fnref n="1" />, PAVOT Arthur<fnref n="2" />, ROUX Damien⁵, PICARD Yoann⁵, MELLATI Nouchan⁴, PHAM Taï<fnref n="2" />, GUMUCIO Victor Daniel<fnref n="3" />, DI PAOLO Fabio A.<fnref n="3" />, COHEN Yves<fnref n="1" />, DREYFUSS Didier⁵, PÉREZ-FERNANDEZ Xosé Luis<fnref n="3" />, GAUDRY Stephane<fnref n="1" />
¹CHU Avicenne, Bobigny, France; ²CHU Kremlin Bicêtre, Kremlin Bicêtre, France; ³Bellvitge University Hospital, Barcelone, Espagne; ⁴CHR Metz Thionvile, Metz, France; ⁵CHU Louis Mourier, Colombes, France

**Correspondence:** Khalil CHAÎBI (khalilchaibi@gmail.com)

*Annals of Intensive Care* 2022, **12**(1):CO-85

**Rationale:** Severe acute kidney injury (AKI) is frequent among critically ill patients with SARS-COV2 infection and associated with high mortality[1]. The epidemiological changes in the rate of severe AKI according to the epidemic waves remain unclear. We evaluated the differences in incidence, risk factors and outcome of severe AKI in patients with SARS-CoV-2 infection between the first and third wave of COVID-19.

**Patients and methods/Materials and methods:** We performed a European multicenter, retrospective observational study in five hospitals in France and Spain from March 1 to March 31, 2020 (first wave) and from March 1 to March 31, 2021 (third wave). We included consecutive adult patients with acute respiratory distress syndrome (ARDS) and testing positive for SARS-CoV-2 in respiratory fluids. Patients with end-stage renal disease or who had sustained cardiac arrest before ICU admission were not included. We reviewed clinical electronic medical records, nursing records, laboratory findings, demographic data, comorbidities, ICU usual parameters, occurrence of severe AKI (defined by KDIGO stage 3)

in the first 7 days after ICU admission and survival outcome 28 days after ICU admission.

**Results:** A total of 445 patients with severe SARS COV2 pneumonia met the inclusion criteria of whom 293 (66%) were admitted during the first wave and 152 (34%) during the third wave. Patients admitted during the third wave had respectively more chronic kidney disease (CKD) at baseline (16.6% VS 7.2% p = 0.020), received more iodinated contrast media (56.6% VS 3.1%), more aminoglycosides (3.9% VS 0.3% p = 0.007) but were less severely ill (SOFA 5 VS 7 p = 0.006). One hundred two (23%) patients experienced severe AKI in the first 7 days of ICU admission. Its cumulative incidence was higher during the first wave than the third (26.8% VS 16.8% p = 0.029) (Fig. 1). In a multivariate Fine and Gray analysis, BMI ≥ 30 was a risk factor of severe AKI during the first (SHR [95CI%] 1.29 [0.81–2.04] p = 0.28) and third wave (SHR [95CI%] 3.35 [1.16–9.64] p = 0.025) whereas CKD was a risk factor only during the first wave (SHR [95CI%] 2.56 [1.23–5.31] p = 0.012). Steroid's administration was not associated with the occurrence of severe AKI.

**Conclusion:** In this multicenter retrospective study including COVID-19 patients with ARDS, severe AKI was more frequent during the first epidemic wave compared to the third one. This may be explained by improvement in critical care delivery and a greater attention to renal impairment.

**Reference 1:** Chaibi K, Dao M, Pham T, Gumucio-Sanguino VD, Di Paolo FA, Pavot A, et al. Severe Acute Kidney Injury in Patients with COVID-19 and Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2020;202:1299–301.

**Compliance with ethics regulations:** Yes in clinical research.

<figure><img src="image_37.png" /><figcaption>Cumulative incidence of severe AKI in the first days after ICU admission according to the first and third wave</figcaption></figure>

## CO-86

**Impact of dexamethasone use in severe COVID-19-induced acute kidney injury**

ORIEUX Arthur<fnref n="1" />, LOUIS Guillaume<fnref n="3" />, GARRIC Antoine<fnref n="2" />, PICARD Yoann<fnref n="3" />, MELLATI Nouchan<fnref n="3" />, PREVEL Renaud<fnref n="1" />, GRUSON Didier<fnref n="1" />,⁴, RUBIN Sébastien<fnref n="2" />,⁵, BOYER Alexandre<fnref n="1" />,⁴

**Correspondence:** Arthur ORIEUX (arthur.orieux@chu-bordeaux.fr)

*Annals of Intensive Care* 2022, **12**(1):CO-86

<footnote n="1">¹Médecine Intensive Réanimation - CHU de Bordeaux, Bordeaux, France;</footnote>

<footnote n="2">²Néphrologie, Transplantation, Dialyse - Aphérèse - CHU de Bordeaux, Bordeaux, France;</footnote>

<footnote n="3">³Réanimation Polyvalente - CHR Metz - Thionville - Hôpital de Mercy, Metz - Thionville, France; ⁴Unité INSERM U1045, Université de Bordeaux, Bordeaux, France., Bordeaux, France; ⁵Unité INSERM U1034, Université de Bordeaux, Bordeaux, France., Bordeaux, France</footnote>
**Rationale:** Since the first wave of COVID-19, the management of patients with severe SARS-CoV-2 infection in intensive care unit (ICU) has changed with the use of dexamethasone (DXM)¹. Acute kidney injury (AKI) in ICU patients with severe COVID-19 was frequent (> 50%). Specific inflammatory process was previously suggested in AKI pathogenesis and could be improved by DXM. A previous study (n = 100 patients) reported a potential protective effect of DXM in AKI incidence². The aim of this study was to investigate in a prospective multicentric study, the impact of DXM in severe COVID-19-induced AKI.

**Patients and methods/Materials and methods:** We carried out a prospective multicentric study in two French ICU from March 1st, 2020 to August 21st, 2021. All patients admitted for a severe COVID-19 in ICU were included. DXM was exclusively used from the second wave. AKI was defined according to the KDIGO classification. Acute kidney disease (AKD) was the persistence of the KDIGO criteria for AKI for ≥ 7 days.

**Results:** 1014 patients were included. 284/1014 patients (28%) were hospitalized in ICU1 and 730/1014 (72%) in ICU2. Mean age was 62.9±12.2 years, 520/1014 (51%) patients had hypertension, 75/1014 (7%) suffered from previous chronic kidney disease (CKD) and 385/1014 (38%) required invasive mechanical ventilation (MV) in the first 24 h. Mean SAPSII was 38.9±15.8 and non-renal SOFA was 4.2±2.4. ICU mortality was 264/1014 (26%). AKI was present in 741/1014 (73%) patients: 266/741 (36%), 173/741 (23%) and 302/741 (41%) had respectively AKI KDIGO 1, 2 and 3 and 88/741 (12%) patients required renal replacement therapy. AKD was observed in 397/741 (54%) of AKI patients. In univariate analysis, DXM exposure decreased AKI incidence: 411/635 (65%) patients vs. 330/379 (87%) patients; OR = 0.27 [0.19–0.38]. In multivariate analysis, DXM use was independently associated with AKI: OR = 0.24 [0.11–0.53] (Table 1). After excluding patients who developed AKI before DXM exposure (n = 186 patients), DXM use remained independently associated with AKI in a similar multivariate model; OR = 0.26 [0.17–0.41]. In univariate analysis, DXM exposure decreased AKD incidence: 207/411 (50%) vs. 190/330 (58%) patients; OR = 0.74 [0.55–0.99] but this effect did not persist in a similar multivariate analysis; OR = 1.17 [0.83–1.66].

**Conclusion:** In our study, DXM exposure decrease AKI incidence in severe COVID-19 patients. These results support the hypothesis that DXM can reduce “inflammatory” AKI incidence (specific of COVID-19 infection) but has no impact on “maladaptive repair” lesions secondary to AKI that can lead to an AKD.

**Reference 1:** The RECOVERY Collaborative Group. Dexamethasone in Hospitalized Patients with Covid-19. N. Engl. J. Med. 384, 693–704 (2021).

**Reference 2:** Orieux, A., Khan, P., Prevel, R. et al. Impact of dexamethasone use to prevent from severe COVID-19-induced acute kidney injury. Crit Care 25, 249 (2021).

**Compliance with ethics regulations:** Yes in clinical research.

<table><caption>Table 1. Multivariate analysis for AKI development</caption><thead><tr><th>Variables</th><th>p value</th><th>Odds ratio</th><th>95% Confidence Interval</th></tr></thead><tbody><tr><td>Dexamethasone use</td><td>&lt;0.001</td><td>0.24</td><td>0.105 - 0.532</td></tr><tr><td>Males</td><td>0.421</td><td>1.29</td><td>0.896 - 2.377</td></tr><tr><td>Age (per year)</td><td>0.030</td><td>1.03</td><td>1.003 - 1.057</td></tr><tr><td>Body mass index (BMI, per point)</td><td>0.495</td><td>1.02</td><td>0.968 - 1.069</td></tr><tr><td>Chronic kidney disease (eGFR &lt;60ml/min/1.73m<sup>2</sup>)</td><td>0.273</td><td>1.72</td><td>0.653 - 4.510</td></tr><tr><td>Hypertension</td><td>0.022</td><td>2.05</td><td>1.109 - 3.783</td></tr><tr><td>Diabetes</td><td>0.497</td><td>0.80</td><td>0.428 - 1.509</td></tr><tr><td>Immunosuppression</td><td>0.652</td><td>1.22</td><td>0.506 - 2.974</td></tr><tr><td>Non-renal SOFA (per point)</td><td>0.043</td><td>1.20</td><td>1.005 - 1.441</td></tr><tr><td>Catecholamine use</td><td>0.226</td><td>0.54</td><td>0.198 - 1.467</td></tr><tr><td>Invasive mechanical ventilation</td><td>0.002</td><td>2.96</td><td>1.482 - 5.921</td></tr><tr><td>Intravenous fluid therapy during 24 first hours (per mL)</td><td>&lt;0.001</td><td>1.003</td><td>1.002 - 1.004</td></tr><tr><td>Tocilizumab use</td><td>0.318</td><td>0.46</td><td>0.099 - 2.115</td></tr><tr><td>Lymphocyte (per GL)</td><td>0.615</td><td>0.98</td><td>0.907 - 1.060</td></tr><tr><td>Aminoglycoside use, before AKI</td><td>0.936</td><td>1.05</td><td>0.349 - 3.138</td></tr></tbody></table>

Multivariate analysis was proceeded using logistic regression. Independent variables were previously described to be associated with AKI or DXM impact. Absence of collinearity was checked.

<caption>Table 1. Multivariate analysis for AKI development</caption>

CO-87

KUNGFU-ECMO Study, kidney upgrades net global filtration under ECMO

PENAUD Victor¹, DUBURCQ Thibault⁴, BUREAU Côme², SALMON-GANDONNIERE Charlotte⁵, ARRESTIER Romain⁶, HENRI Samuel⁴, DRES Martin², JACQUIER Sophie⁵, DE PROST Nicolas⁶, GIRAUD Raphael³, RICARD Jean-Damien¹, ROUX Damien¹, UHEL Fabrice¹, LEGOUIS David³, VERNEY Charles¹

¹AP-HP, Hôpital Louis Mourier, Colombes, France; ²AP-HP, Hôpital Pitié Salpêtrière, Paris, France; ³Hôpitaux Universitaires de Genève, Genève, Suisse; ⁴Centre Hospitalier Universitaire de Lille, Lille, France; ⁵Centre Hospitalier Régional Universitaire de Tours, Tours, France; ⁶AP-HP, Hôpital Henri Mondor, Créteil, France

**Correspondence:** Charles VERNEY (charlesverney@gmail.com)

Annals of Intensive Care 2022, **12**(1):CO-87

**Rationale:** Acute kidney injury (AKI) is frequently observed in acute respiratory distress syndrome (ARDS). Risk factors for AKI include positive end expiratory pressure (PEEP), severity of ARDS and fluid overload, possibly linked to renal congestion. There is no data on the evolution of renal function in patients presenting severe ARDS and requiring extra-corporeal membrane oxygenation (ECMO) implantation. Veino-veinous ECMO (VV-ECMO) could prevent AKI by alleviating this renal congestion with the aspiration of the femoral canula. We aim to study how a VV-ECMO modified the renal function in this population.

**Patients and methods/Materials and methods:** We performed a multicentre retrospective study, between 2011 and 2021, in six intensive care units in France and Switzerland. Inclusion criteria were: adult patients presenting a severe ARDS requiring VV-ECMO, with available data regarding daily urine output and blood tests 2 days before and three days after implantation. Patients receiving renal replacement therapy (RRT) before day three or veino-arterial ECMO or those who did not agree to participate were excluded. The primary outcome was the evolution of the serum creatinine level after VV-ECMO implantation. Daily urine output and evolution of biochemical parameters in urine samples after implantation were the secondary outcomes.

**Results:** Ninety-nine patients were included, with a median age of 53 years, of which 30% were women. ECMO implantation occurred after a median duration of mechanical ventilation of 6 days. COVID-19 was the main cause in 72% of ARDS. The evolution of the serum creatinine level did not significantly differ before and after implantation (p = 0.2). In contrast, ECMO implantation was associated with a significant increase in daily urine output (+6.3 mL/kg/day, p < 0.001), even after adjustment for potential confounding factors (including PEEP, duration of mechanical ventilation, fluid balance, cause of ARDS, and diuretics). Fractional excretion of urea and natriuresis were also significantly increased after ECMO implantation (respectively +10%, p < 0.001 et +20 mmol/L, p < 0.001). Finally, the increase in urine output under ECMO was negatively associated with the risk to receive RRT after day three (p = 0.047).

**Conclusion:** VV-ECMO implantation for severe ARDS is associated with an increase in daily urine output and natriuresis. This diuretic like effect does not modify the glomerular filtration following implantation. Prospective studies are necessary to better define renal hemodynamic and tubular modifications occurring under VV-ECMO, and the potential improvement in the management of fluid overload in this context.

**Compliance with ethics regulations:** Yes in clinical research.

<figure><img src="image_38.png" /></figure>
Evolution of serum creatinine level, daily urine output, Fractional excretion or urea, measured creatinine clearance with UV/P formula and natriuresis, between 2 days before and 3 days after implantation of VV-ECMO.

## CO-88

**Urinary CCL14 biomarker to predict renal replacement therapy initiation in critically ill patients with severe acute kidney injury?**

CHAÎBI Khalil¹, PLACIER Sandrine², LOUIS Guillaume³, MARTIN-LEFEVRE Laurent⁴, TITECA Dimitri⁵, LACOMBE Béatrice⁶, BESSET Sébastien⁷, BADIE Julio⁸, CHEVREL Guillaume⁹, CHUDEAU Nicolas¹⁰, BARBAR Saber¹¹, VINSONNEAU Christophe¹², FOREL Jean-Marie¹³, THEVENIN Didier¹⁴, LACAVE Guillaume¹⁵, NSEIR Saad¹⁶, POIRSON Florent¹, MAYAUX Julen¹⁷, KLOUCHE Kada¹⁸, REIGNIER Jean²⁰, QUENOT Jean-Pierre²¹, HADCHOUEL Juliette², DREYFUSS Didier², GAUDRY Stéphane¹

¹CHU Avicenne, Bobigny, France; ²INSERM CORAKID UMRS1155, Paris, France; ³CHR Metz-Thionville Hôpital de Mercy, Metz, France; ⁴CHR départementale La Roche Sur Yon, La Roche Sur Yon, France; ⁵CHU d'Amiens Picardie, Amiens, France; ⁶CH de Bretagne Sud, Lorient, France; ⁷Hôpital Louis Mourier, Colombes, France; ⁸Hôpital Nord Franche-Comte, Belfort, France; ⁹CH Sud Francilien, Corbeil Essones, France; ¹⁰CH du Mans, Le Mans, France; ¹¹Hôpital Caremeau, Nimes, France; ¹²CH Bethune Beuvry - Bermont et Gauthier, Bethune, France; ¹³Hôpital Nord, Marseille, France; ¹⁴CH Dr Schaffner, Lens, France; ¹⁵Hôpital André Mignot, Versailles, France; ¹⁶CHRU de Lille, Hôpital Roger Salengro, Lille, France; ¹⁷Hôpital Pitié Salpêtrière, Paris, France; ¹⁸Hôpital Lapeyronnie, Montpellier, France; ¹⁹Hôpital Avicenne, Bobigny, France; ²⁰Hôtel Dieu, Nantes, France; ²¹François Mitterrand University Hospital, Dijon, France

**Correspondence:** Khalil CHAÎBI (khalilchaibi@gmail.com)

*Annals of Intensive Care* 2022, **12**(1):CO-88

**Rationale:** Recent trials confirmed that an early renal replacement therapy (RRT) initiation does not confer any survival benefice compared with a delayed one during severe acute kidney injury (AKI) when no severe complications are present. Tools to enable personalized management are still needed and evidence for biomarkers guided RRT initiation are lacking[1]. In a cohort of critically ill patients with AKI, an elevation in urinary CCL14 could predict the persistence/progression of AKI [2]. We aimed to assess the utility of urinary CCL14 for the prediction of RRT initiation in a conservative approach in Intensive Care Unit (ICU).

**Patients and methods/Materials and methods:** In an ancillary study of AKIKI2 (Comparison of two delayed strategies for renal replacement therapy initiation for severe acute kidney injury), we included ICU patients with severe AKI (stage 3 KDIGO) and available urinary sample at the first day of severe AKI. We did not include patients with chronic kidney disease. CCL14 was measured by enzyme-linked immunosorbent assay (ELISA) in urinary samples at D0. The primary endpoint was the occurrence of a criteria for RRT (according to a conservative approach of RRT initiation) within the 72 h after severe AKI. Those criteria were: life threatening complication of AKI, or oliguria/anuria (urine output <0.3 mL/kg per h or <500 mL/day) for more than 72 h, or serum urea concentration of 40 mmol/L or more.

**Results:** A total of 230 patients were enrolled. Ninety patients (39.1%) met the primary endpoint. Urinary CCL14 was not associated with serum creatinine concentration at D0 (Pearson correlation r² = 0.024). Median urinary CCL14 was 15.03 (IQR 24.88) mg/ml in patients reaching the primary endpoint and 5.8 (IQR 12.18) mg/ml in patients who did not (p < 0.001). In multivariate analysis, urinary CCL14 (OR = 1.02, [1.01;1.04], p = 0.0021) was associated with higher rate of occurrence of a criteria of RRT initiation. The area under the ROC curve was 0.701 (95% CI: [0.633;0.770]) for urinary CCL14 to predict the occurrence of a criteria of RRT initiation within 72 h after severe AKI (Fig. 1).

**Conclusion:** Although interesting, urinary CCL14 alone might not be precise enough to discriminate patients with RRT initiation criteria in a conservative approach. However, it might be useful when used in combination with other clinical or biological variables.

**Reference 1:** Ostermann M, Lumlertgul N. Wait and see for acute dialysis: but for how long? The Lancet. 2021;397:1241-3.

**Reference 2:** Hoste E, Bihorac A, Al-Khafaji A, Ortega LM, Ostermann M, Haase M, et al. Identification and validation of biomarkers of

persistent acute kidney injury: the RUBY study. Intensive Care Med. 2020;46:943-53.

**Compliance with ethics regulations:** Yes in clinical research.

<figure><img src="image_39.png" /></figure>

Receiver operating characteristic (ROC) curve for prediction of RRT initiation criteria with urinary CCL14

## CO-89

**Concurrent treatment with angiotensin 1-7 in septic shock**

GARCIA Bruno¹, ANNONI Filippo¹, SU Fuhong¹, HERPAIN Antoine¹, TACCONE Fabio¹, CRETEUR Jacques¹

¹Laboratoire experimental des soins intensifs de l'hôpital Erasme, Bruxelles, Belgique

**Correspondence:** Bruno GARCIA (br.garcia@icloud.com)

*Annals of Intensive Care* 2022, **12**(1):CO-89

**Rationale:** Renin-angiotensin system is activated during sepsis and septic shock. Its main effector, angiotensin II, is responsible for pro-inflammatory effects and endothelial dysfunction. Angiotensin (1-7) (Ang (1-7)), an active peptide produced by angiotensin-converting enzyme type 2 (ACE2), has opposite effects and has been reported to prevent organ damage during sepsis in mice. Our study aimed to assess the effect of concurrent treatment with ang (1-7) on sepsis outcome.

**Patients and methods/Materials and methods:** Sepsis was induced by fecal peritonitis in sixteen mechanically ventilated, hemodynamically monitored female sheep. Animals were randomized to two groups: control or concurrent treatment group (n = 8 each) after surgical preparation and stabilization. Angiotensin (1-7) at 10 mcg/kg/h was started at sepsis inducement in the concurrent treatment group. Four hours after feces injection, fluid resuscitation (pulse pressure variation ≤ 13%), antibiotherapy, and peritoneal lavage were administered, and norepinephrine was given to maintain mean arterial blood pressure ≥ 65 mmHg if necessary. The experiment lasted for 24 h.

**Results:** No difference was found among groups regarding baseline demography. During the first 4 h, MAP was dropped significantly in the control group. All the animals in the control group developed a septic shock. A significantly lower dose of norepinephrine was utilized in the concurrent treatment group. Creatinine, platelet count, PaO₂/FiO₂, pH, and lactate levels were significantly lower in the concurrent treatment group. Two animals died in the control group before the end of the experiment.

**Discussion:** In this mechanical ventilated, hemodynamically monitored sepsis model; concurrent treatment with ang (1-7) significantly reduced norepinephrine requirements and attenuated organ dysfunction. Ang (1-7) can reduce inflammation by the activation of the Mas receptor, and reduce cytokine storm. However, the risk of the effects on the immune system is not well described in the literature and could expose to secondary infections. This is the first use of Ang (1-7) in a large clinically relevant animal model characterized by fluid
resuscitation based on dynamic parameters, broad-spectrum anti-
biotherapy, peritoneal lavage, and vasopressors. Polymicrobial sepsis,
induced by feces injection, was able to develop a severe septic shock
with organ dysfunction. The protocol followed the recent guidelines
on septic shock resuscitation and guidelines for Minimum Quality
Threshold in Pre-Clinical Sepsis Studies (MQTiPSS).

**Conclusion:** Concurrent treatment with Ang (1–7) reduced sever-
ity of septic shock. Further studies are needed to assess the timing of
administration, dose and duration of Ang (1–7) in sepsis.

**Compliance with ethics regulations:** Yes in animal testing.

<figure><img src="image_40.png" /></figure>

Results

CO-90

Renal prognosis of elderly TTP patients on caplacizumab therapy
(the Repeto-capla study)

CARNIATO Flavie¹, LESCROART Mickael¹, ZAFRANI Lara¹, AZOULAY Elie¹,
VEYRADIER Agnès², COPPO Paul³, MARIOTTE Eric¹

¹Hôpital Saint-Louis, Paris 10E, France; ²Hôpital Lariboière, Paris 10E, France; ³Hôpital Saint-Antoine, Paris 12E, France

**Correspondence:** Flavie CARNIATO (flavie.carniato@gmail.com)

Annals of Intensive Care 2022, **12**(1):CO-90

**Rationale:** Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy caused by a severe ADAMTS13 activity deficiency. Mortality in TTP sharply decreased with the introduction of emergency therapeutic plasma exchanges (TPE) and immunomodulation; however, elderly patients remain at high risk of mortality and severe organ involvements, including acute renal failure. More recently, the adjunction of Caplacizumab has improved time to recovery in TTP patients. The association of caplacizumab administration with improved renal function in elderly patients with TTP is unknown.

**Patients and methods/Materials and methods:** In this retrospective study, we described the characteristics and outcome of TTP patients aged over 60 years. They were enrolled from 2000 to 2021 in the French national reference center for thrombotic microangiopathy registry according to treatment with standard of care (SOC, consisting of TPE, steroids and for most rituximab) with or without Caplacizumab (C+ and C- groups). Results are presented as number (%) or median (interquartile range). Comparisons were made using Chi² or Mann-Whitney tests as appropriate.

**Results:** Sixty-three patients met inclusion criteria, including 35 females (55%) aged 70 yo (65-75). Thirty-four (54%) patients received C- and 28 C+. Patients' medical history and baseline characteristics were similar between both groups, including frequency of chronic kidney disease (14%), neurological involvement (79%), platelet rate (16G/L(9-24)), hemoglobin level (8.9 g/dL(8-10)), elevated troponin (68%) and Glomerular Filtration Rate (GFR, 51 ml/min/1.73 m²(35-77)). All C+ patients received Rituximab versus 65% of C- (p < 0.05). Caplacizumab was administered 2 (1.5-7.5) days after admission, for 30 (21-37) days, with frequent adverse effects (53%). Time to platelet count normalization was shorter with C+ (4 days vs 8, p < 0.05). C+ patients

needed less TPE (5(4-8) sessions vs 11(6-16), p < 0.05) and experienced no case of refractory TTP. All patients requiring renal replacement therapy (RRT) belonged to the C- group (18% vs 0%, p = 0.056). For others, GFR was similar at discharge (C+ 78(59-94) mL/min/1.73 m² vs C- 62(42-86) mL/min/1.73 m², p = 0.11). Hospital mortality was higher in the C- group than in the C+ group (38% vs 3.5%, p < 0.05). After a follow up of 165 (24-630) days, 1/3 of patients requiring RRT during initial hospitalization were RRT-free. For others, GFR was similar (C+ 78(64-90) mL/min/1.73 m² vs C- 62(42-80) mL/min/1.73 m², p = 0.24).

**Conclusion:** Our results should be influenced by the fact that C-
patients were managed during the earlier period of the study and
received different SOC, including a lower frequency of rituximab use.
In this study, Caplacizumab seemed to improve outcome in elderly
TTP patients with no clear effect on renal dysfunction.

**Compliance with ethics regulations:** Yes in clinical research.

Flash communications

FC-001

Epidemiological profile of burns in children admitted
to the casablanca national burns center

CHAKIR Anass¹, MOKAKO Jacques², HABLA Marouane², ELHARTI Anas²,
DIOURI Mounia²

¹Département d'anesthésie et de réanimation, Centre hospitalier
universitaire Ibn Rochd, Casablanca, Maroc; ²Centre national des brûlés
et de chirurgie réparatrice, Centre Hospitalier Universitaire Ibn Rochd,
Casablanca, Maroc

**Correspondence:** Youssef HAOUAS (h.youssef414@gmail.com)

Annals of Intensive Care 2022, **12**(1):FC-001

**Rationale:** This retrospective work of the last 3 years (January 2018-March 2021) analyzes the epidemiological characteristics of 1156 cases of burnt children aged 0-17 years admitted to the National Burn Center emergency room so that these data serve as a basis for the development of a program of prevention, adequate, fast and effective treatment of burnt children. The age group from 1 month to 2 years was the most affected with 587 cases or 50.77% of patients.

**Patients and methods/Materials and methods:** Male involvement is found in 54% of cases, i.e. 624 patients. Burns occur at home in 99.48% of cases, i.e. 1,150 patients, and accidentally in 99.39% of cases, i.e. 1,149 patients.

**Results:** Thermal burns accounted for 98.78% of cases or 1,142 patients, dominated by liquids in 77.94% of cases or 901 patients. The burnt skin surface was ≥10% in 44% of cases, i.e. 509 patients. The burn mainly concerns upper limbs 57% of cases or 659 patients. The mortality rate was 7.61% or 39 patients.

**Conclusion:** This work also includes a retrospective comparison of the COVID period (March 2020-March 2021) to the pre-COVID period (March 2019-February 2020) during which the number of emergencies had increased by 24 additional patients (370 versus 346) with hospitalization an increase of 3.14% (171 versus 149) and during which 1 child had tested positive for COVID 19. During this comparative period the mortality rate was down by 1.77% (5 versus 7).

**Compliance with ethics regulations:** Yes in clinical research.

FC-002

Changes in management practices for moderate to severe
bronchiolitis in infants between 2010 and 2020: a retrospective
study conducted in the pediatric intensive care unit

LESUEUR Simon¹, SAVY Nadia¹

¹CHU Clermont Ferrand, Clermont Ferrand, France

**Correspondence:** Simon LESUEUR (simon.lesueur31@gmail.com)

Annals of Intensive Care 2022, **12**(1):FC-002
**Rationale:** Acute bronchiolitis represents 8 to 13% of respiratory distress hospitalised in Pediatric Intensive Care Units (PICUs). The main challenge of care is the early management of respiratory failure and digestive intolerance. In the PICU, our practice has been to use the High Flow Nasal Cannula (HFNC) almost exclusively, due to its ease of use and good tolerance, despite the fact that the latest trials do not demonstrate its non-inferiority compared to CPAP. With this study, we would like to highlight an improvement in the quality of care and well-being of our patients with moderate to severe bronchiolitis.

**Patients and methods/Materials and methods:** This is a retrospective descriptive study conducted over two periods P1 (2010–2013) and P2 (2017–2020) in the PICU on infants with moderate to severe acute bronchiolitis. The main objective of our study is to evaluate the improvement of the quality of care over time through a composite criterion: the use of antibiotic therapy and the time to complete enteral feeding, by comparing them over the two distinct periods. The secondary endpoints were comparisons of clinical and therapeutic data.

**Results:** Our analysis involved 106 patients, 45 in the first period P1 and 61 in the second period P2, matched for severity and age. Antibiotic use decreased over the decade (66.7% vs. 37.7%, p < 0.05) and completion of full enteral feeding tended to be shorter (3.1 (± 1.5) days vs. 2.6 (1.2) days respectively; p = 0.08). The use of HFNC as first-line treatment increased significantly over the decade (33.3% vs 96.7%; p < 0.05) at the expense of CPAP, which is no longer used on P2. More aggressive care tended to decrease with lower rates of intubation (1.6% vs 8.9%; p = 0.16) and less intravenous glucose solution infusion (60.7% vs 91.1%; p < 0.05). Complication rates were low and similar in both periods. However, the total duration of ventilation was shorter on P1 with 4.5 (± 3.0) days compared to 5.5 (± 2.7) days on P2; p = 0.07.

**Conclusion:** The quality of care in our unit has improved over the last decade with greater adherence to international guidelines regarding decreased antibiotic use and preference for enteral intake over infusion.

**Compliance with ethics regulations:** Yes in clinical research.

## FC-003

### Impact of the Nusinersen on the number of hospitalisations in pediatric intensive care units for respiratory decompensation in children with spinal muscular atrophy over the period 2015–2021

BAKAYOKO Awa<fnref n="1" />, VAUGIER Isabelle<fnref n="1" />, MBIELEU Blaise<fnref n="1" />, ESSID Aben<fnref n="1" />, ZINI Justine<fnref n="1" />, BELTAIEF Emna<fnref n="1" />, GUILLON Maud<fnref n="1" />, FAYSSOIL Abdallah<fnref n="1" />, GOMEZ GARCIA DE LA BANDA Marta<fnref n="1" />, QUIJANO ROY Susana<fnref n="1" />, BERGOUNIOUX Jean<fnref n="1" />

**Correspondence:** Awa BAKAYOKO (awa.bakayoko@aphp.fr)

Annals of Intensive Care 2022, **12**(1):FC-003

**Rationale:** Spinal muscular atrophy is a neuromuscular disease of genetic origin. It is the leading genetic cause of infant mortality. Worldwide, the prevalence of this disease is estimated at 1 in 10,000 births. The genes involved are the SMN1 and SMN2 genes, located on chromosome 5, whose deletion leads to the destruction of motor neurons, which results in an impairment of respiratory function. Nusinersen is the first curative drug developed for the treatment of spinal muscular atrophy. It is an antisense oligonucleotide that binds to the pre-messenger RNA of the SMN2 gene, allowing the production of the SMN protein, and thus leading to improved motor control. The aim of this study was to evaluate the impact of Nusinersen on the admission to the pediatric intensive care unit in our hospital, for respiratory decompensation in children with spinal muscular atrophy.

**Patients and methods/Materials and methods:** Retrospective comparative study of the reasons for admission to a pediatric intensive care unit in children with spinal muscular atrophy, treated or not by Nusinersen, over the period 2015–2021.

**Results:** 69 patients with spinal muscular atrophy were hospitalised in our Intensive Care Unit between 2015–2021; 108 passages were related to respiratory decompensation, representing 41 patients. There has been a significant decrease in hospital admissions for respiratory decompensation in SMA over the last 4 years, which we were able to statistically correlate with the implementation of Nusinersen treatment (results under analysis).

**Conclusion:** We observed a significant decrease in hospitalisations for respiratory decompensation in the intensive care of unit of patients with AMSI and this correlated with the administration of Nusinersen.

**Compliance with ethics regulations:** N/A.

## FC-004

### Work of breathing during non invasive ventilation in severe acute bronchiolitis

VEDRENNE-CLOQUET Meryl<fnref n="1" />, KHIRANI Sonia<fnref n="1" />, GRIFFON Lucie<fnref n="1" />, COLLIGNON Charlotte<fnref n="1" />, RENOLLEAU Sylvain<fnref n="1" />, FAUROUX Brigitte<fnref n="1" />

**Correspondence:** Meryl VEDRENNE-CLOQUET (meryl.vedrenne@aphp.fr)

Annals of Intensive Care 2022, **12**(1):FC-004

**Rationale:** Continuous positive airway pressure (CPAP) has been shown to reduce the work of breathing (WOB) during severe acute bronchiolitis. Noninvasive Positive Pressure Ventilation (NIPPV) is also used in this condition but no study has compared NIPPV to CPAP. We aimed to compare WOB during CPAP and NIPPV in infants with acute bronchiolitis.

**Patients and methods/Materials and methods:** Infants < 6 months of age with bronchiolitis were included if they needed noninvasive respiratory support (NRS) within the first 24 h. Exclusion criteria included contra-indication for nasogastric tube, imminent intubation, neuromuscular disease, parental refusal. NRS was initiated by the attending physician according to local practice: CPAP + 7 cmH₂O was the first-line setting, with NIPPV, set on clinical parameters and child's comfort, being reserved for CPAP failure. Oesophageal (PES) and gastric pressures were measured using a nasogastric catheter (Gaeltec™). The study started with a first period with the baseline NRS (CPAP or NIPPV), followed by a 5-min washout (spontaneous breathing). Afterward, a second period was performed with the other NRS. Within each period, a first recording was performed with the clinical settings (Clin) and a second with a physiological setting (Phys) aiming at normalizing WOB. For CPAPPhys, the CPAP level was increased from 6 to 10 cmH₂O. For NIPPVPhys, initial inspiratory pressure was set at + 4 cmH₂O above CPAP, and progressively increased, with inspiratory and expiratory triggers set to optimize synchronization. The “optimal” NRS was the one associated with an optimal reduction in clinical symptoms, PTCO₂ (Sentec™), and estimated WOB (PTPES/min = AUC of PES during inspiration × Respiratory Rate) over 10 stable breaths.

**Results:** 20 children were included, with a median [IQR] age of 1.4[0.8; 2.9] months and a median weight of 4[3.5; 5.2] kilograms. Twelve infants had CPAP at baseline: CPAP remained the optimal mode in 7, whereas NIPPV was superior in 5. Eight infants had NIPPV at baseline: NIPPV remained the optimal mode in 2, whereas CPAP was superior in 6 (Figure).

**Conclusion:** CPAP was associated with a decrease in WOB in the majority of infants with acute bronchiolitis. NIPPV may be superior to CPAP in some infants. Predictive factors associated with a need for NIPPV were not identified in the present study.

**Compliance with ethics regulations:** Yes in clinical research.

<footnote n="1">¹ Hôpital Raymond-Poincaré, Garches, France</footnote>

<footnote n="1">¹Necker-Enfants Malades, Paris, France</footnote>
<figure><img src="image_41.png" /><figcaption>Study flow chart</figcaption></figure>

### FC-005

#### Continuous determination of optimal mean arterial pressures based on cerebral autoregulation after pediatric cardiac surgery

TABONE Laurence¹, EL-TANNOURY Jihad¹, LEVY Michaël³, SAUTHIER Michael¹, JORAM Nicolas², BOURGOUIN Pierre², AL-OMAR Sally¹, EMERIAUD Guillaume¹, THIBAULT Céline¹

¹CHU Sainte Justine, Montréal, Canada; ²CHU de Nantes, Nantes, France;

³CHU Robert Debré, Paris, France

**Correspondence:** Laurence TABONE (lau.tabone@gmail.com)

Annals of Intensive Care 2022, **12**(1):FC-005

**Rationale:** Neuroprotection is a major concern in children with congenital heart diseases. Cerebrovascular autoregulation (CAR) is the capacity of cerebral vessels to ensure a constant blood flow in a given range of mean arterial pressures (MAP) and may be a modifiable perioperative factor influencing outcomes. CAR has been shown to be altered before and during cardiopulmonary bypass, but has not yet been described in the postoperative period. The cerebral oximetry index (COx) estimates CAR by correlating regional cerebral oxygenation and MAP. By plotting COx against MAP, the optimal MAP (opt-MAP) and the lower and upper limits of MAP corresponding to optimal CAR (LLA and ULA) can be determined. Our aim was to evaluate the feasibility of continuously determining the opt-MAP, LLA, and ULA in children within 48 h of cardiac surgery and to describe CAR parameters according to age and postoperative time frame.

**Patients and methods/Materials and methods:** Using a high-frequency database, we retrospectively included all children admitted in a single pediatric intensive care unit (PICU) after cardiac surgery between May 2020 and June 2021. An algorithm for the continuous calculation of the opt-MAP, LLA, and LLA was developed using a weighted combination of 40 time windows for the calculation of COx and opt-MAP. CAR results were described according to four predefined age groups and postoperative time frames. We calculated the percentage of time with MAP outside the range of LLA to ULA. Results are reported as median [interquartiles] and comparisons between age groups and postoperative time periods were performed using Wilcoxon and Kruskal-Wallis tests.

**Results:** Fifty-one children were included with a median monitoring time of 42 [23–44] hours. Opt-MAP, LLA, and ULA were determined 92% [88–95] of the time, with first results available 74.0 [IQR 60.0–105.0] minutes after PICU admission. Lower opt-MAP were observed in neonates <1 month old (Table). Children spent 25% [18–31] of their time with MAP outside the optimal CAR range, with no significant difference between age groups or periods.

**Conclusion:** The continuous calculation of Opt-MAP, LLA and ULA is feasible in children after cardiac surgery using signals routinely available in clinical practice. Children spent a significant proportion of time outside the optimal range of MAP based on CAR. Further research is

warranted to explore the potential impacts of this deviation on neurological outcomes.

**Compliance with ethics regulations:** Yes in clinical research.

<table><thead><tr><th></th><th>All patients<br>(n= 51)</th><th>Group 1<br>(≤ 1 month)<br>(n= 18)</th><th>Group 2<br>(1 month - 5 years)<br>(n= 13)</th><th>Group 3<br>(1-5 years)<br>(n= 13)</th><th>Group 4<br>(≥ 5 years)<br>(n= 10)</th><th>p</th></tr></thead><tbody><tr><td>rSO₂(%)</td><td>70 (64, 74)</td><td>66 (62, 73)</td><td>67 (65, 71)</td><td>69 (63, 72)</td><td>81 (75, 82)*</td><td>0.004</td></tr><tr><td>MAP (mmHg)</td><td>58 (51, 68)</td><td>50 (48, 52) §</td><td>60 (55, 73)</td><td>63 (61, 71)</td><td>72 (67, 73)</td><td>&lt;0.001</td></tr><tr><td>Opt-MAP (mmHg)</td><td>61 (52, 71)</td><td>50 (48, 52) §</td><td>60 (55, 73)</td><td>63 (61, 71)</td><td>72 (67, 73)</td><td>&lt;0.001</td></tr><tr><td>LLA (mmHg)</td><td>53(45, 62)</td><td>43 (42, 45) §</td><td>53 (48, 63)</td><td>56 (53, 60)</td><td>63 (59, 66)</td><td>&lt;0.001</td></tr><tr><td>ULA (mmHg)</td><td>67 (58, 77)</td><td>58 (54, 59) §</td><td>67 (60, 79)</td><td>72 (66, 77)</td><td>78 (73, 80)</td><td>&lt;0.001</td></tr><tr><td>Range of intact CAR (mmHg)</td><td>13 (11, 15)</td><td>13 (11, 14)</td><td>13 (10, 18)</td><td>14 (12, 16)</td><td>13 (11, 14)</td><td>0.835</td></tr><tr><td>% of time with opt MAP</td><td>92 (88, 95)</td><td>91 (87, 96)</td><td>94 (91, 96)</td><td>92 (89, 94)</td><td>89 (85, 91)</td><td>0.190</td></tr><tr><td>% of time with MAP outside the range of intact CAR</td><td>25 (18, 31)</td><td>22 (18, 27)</td><td>23 (20, 37)</td><td>27 (23, 32)</td><td>25 (18, 35)</td><td>0.645</td></tr><tr><td>% of time with MAP>ULA</td><td>9 (6, 10)</td><td>9 (6, 11)</td><td>8 (3, 10)</td><td>8 (7, 10)</td><td>7 (5, 12)</td><td>0.793</td></tr><tr><td>% of time with MAP<LLA</td><td>16 (11, 22)</td><td>14 (8, 17)</td><td>21 (12, 25)</td><td>20 (13, 21)</td><td>19 (11, 24)</td><td>0.157</td></tr></tbody></table>

Data are expressed as median (interquartile range)

*Significantly different from group 1, 2 and 3; § significantly different from group 2, 3 and 4

CAR: cerebral autoregulation, COx: cerebral oximetry index, LLA: lower cerebral autoregulation limit, MAP: mean arterial pressure, Opt-MAP: optimal MAP, rSO₂: regional cerebral tissue oximetry, ULA: upper cerebral autoregulation limit.

### Cerebral autoregulation parameters according to age groups

### FC-006

#### Optical thermography infrastructure to assess thermal distribution in critically ill children

SHCHERBAKOVA Monisha¹,², NOUMEIRA Rita², LEVY Michael¹, BRIDIER Armelle¹, LESTRADE Victor¹, JOUVET Philippe¹

¹CHU Sainte Justine, Montreal, Canada; ²Ecole de technologie supérieure, Montreal, Canada

**Correspondence:** Monisha SHCHERBAKOVA (monisha.shcherbakova.hsj@ssss.gouv.qc.ca)

Annals of Intensive Care 2022, **12**(1):FC-006

**Rationale:** The body temperature distribution at the skin surface could be used to monitor changes in cardiac output [1]. The aim of this study was to explore infrared thermography (IRT) as a non-invasive and reliable method to analyze core body temperature of critically ill children and assess the clinical value of temperature evolution across different parts of the body.

**Patients and methods/Materials and methods:** Patients admitted to the pediatric intensive care unit (PICU) were included in this study after parental consent was obtained (approved by the CHU Ste-Justine Research Ethics Board). An infrared sensor (Lepton 3.0 & 3.5 Thermal Camera, Teledyne FLIR, Canada) was used to take infrared (IR) images in clinical conditions. The infrared core and limb temperatures (θc, & θi) were extracted. A line was drawn on the IR images starting from the center (eyes/internal canthus or thorax) and running along the limbs to the extremities. The temperature along this line was extracted and plotted on a graph, to study how the temperature modulates across the body. The gradient was calculated by taking the difference between the core (θc) and limb (θi) temperatures extracted from the images. The correlation between values was assessed by Spearman's correlation coefficient.

**Results:** In total, 36 patients were included. Their median age was 8 months [1–64.5], 7.4 kg [4.5–24.6]. The median [interquartile range] for θc extracted from the images was 33.9 °C [32.7–34.2 °C] and the median θi was 30.2 °C [28.9–33.1 °C]. There was a good correlation between the θc and the clinical axillary temperature (rho = 0.39 and p-value = 0.016). The median thermal gradient was 3.2 °C (1.1–4.6) and the maximum gradient was 6.0 °C. The temperature gradient across the body was subject to many artefacts (Fig. 1). Due to the low number of patients with hemodynamic instability, we could not study the correlation between thermal gradient and clinical status. Surprisingly, we observed a child with a negative thermal gradient (− 1.14 °C) i.e. higher temperature on the extremities (fingers) compared to the thorax. This child had a cardiac surgery and was treated with a vasodilator (milrinone).
**Conclusion:** The study documented that the thermal gradient was easily manually calculated. The automatic thermal gradients calculation needs further work to have an adequate segmentation and to identify artefacts. Further work is also needed to document the added value of monitoring changes in the thermal gradient over time to assist in the management of critically ill children with hemodynamic instability.

**Reference 1:** [1] Ferraris A, Bouisse C, Mottard N, Thiollière F, Anseilin S, Piriou V, et al. Mottling score and skin temperature in septic shock: Relation and impact on prognosis in ICU. PLoS One. 2018;13(8):e0202329.

**Compliance with ethics regulations:** Yes in clinical research.

<figure><img src="image_42.png" /></figure>

IR image taken as part of the study, with a line joining the core (eyes) down to the extremities of the leg. The adjoining graph depicts the temperature as it changes along this line.

### FC-007

#### Trend over three decades of the stated practice pattern on the hemoglobin (Hb) threshold that would guide red blood cell (RBC) transfusion practice in pediatric intensive care units, on behalf of the CCCTG, PCCS, JICRG and GFRUP

GALLAND Anne¹, TUCCI Marisa¹, LETEUURTRE Stéphane², SARFATTI Avishay³, RAY Samiran⁴, STANWORTH Simon⁵, FONTELA Patricia⁶, KAWA GUCHI Atsushi⁷, DEMARET Pierre⁸, DUCRUET Thierre⁹, LACROIX Jacques¹, DU PONT-THIBODEAU Geneviève¹

¹Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, Canada; ²Réanimation et Surveillance Continue Pédiatriques, Hôpital Jeanne de Flandre, CHRU Lille, Lille, France; ³Department of Pediatrics, Oxford University Hospitals NHS Foundation Trust, Oxford, Royaume-Uni; ⁴Department of Pediatrics, Great Ormond Street Hospital, London, Royaume-Uni; ⁵Transfusion Medicine, Department: Haematology, NHS Blood & Transplant/Oxford Radcliffe Hospitals, Oxford, Royaume-Uni; ⁶Pediatric Critical Care, Departments of Pediatrics and of Epidemiology, Biostatistics, and Occupational Health, The Montreal Children's Hospital, McGill University, Montreal, Canada; ⁷Pediatric Intensive Care Unit, Tokyo Women's Medical University, Department of Intensive Care Medicine, Tokyo, Japan; ⁸Pediatric intensive care unit, Department of Pediatrics, CHC Liège, Liège, Belgique; ⁹Unité de recherches cliniques appliquées, Research Centre, CHU Sainte-Justine, Montréal, Canada

**Correspondence:** Jacques LACROIX (jlacroix052@gmail.com)

Annals of Intensive Care 2022, **12**(1):FC-007

**Rationale:** To determine the trend over three decades of the stated practice pattern of pediatric intensivist on the Hb threshold that guides their RBC transfusion practice.

**Patients and methods/Materials and methods:** Three scenario-based self-administered questionnaires were filled by 163, 125 and 132 respondents in 1997, 2010 and 2021, respectively. Three scenarios were similar in these surveys: 1) previously healthy 4-year-old boy mechanically-ventilated after a severe multiple trauma; 2) idem with septic shock; 3) 5-month-old boy admitted to a Pediatric Intensive Care Unit (PICU) following corrective surgery for tetralogy of Fallot. Patients were hemodynamically stable in all scenarios. The question asked after each scenario was: what Hb concentration would prompt you to prescribe an RBC transfusion to this patient?

**Results:** Figure 1 reports the practice pattern stated in 1997, 2010 and 2021. For all scenarios, all respondents (100%) should have chosen to prescribe an RBC transfusion only if the Hb level was

**Conclusion:** The TRIPICU study, a non-inferiority randomized controlled trial (RCT) led by Lacroix et al. (N Engl J Med 2007;356:1609–19), enrolled 637 hemodynamically stable critically ill children who had Hb concentration ≤ 9.5 g/dL; it showed that a Hb threshold of 7 g/dL for RBC transfusion is not inferior to a threshold of 9.5 g/dL (absolute risk reduction with the restrictive strategy, 0.4%; 95% confidence interval, -4.6 to 5.4) and that it can decrease transfusion requirements in PICU patients without increasing adverse outcomes. The main recommendation of TRIPICU was not giving an RBC transfusion to hemodynamically stable PICU patients if their Hb concentration is ≥ 7 g/dL. The RCT led by Cholette et al. (Ann Thorac Surg 2017;103:206–14) that enrolled 134 cardiac children weighing ≤ 10 kg undergoing biventricular repair cardiac surgery and the RCT led by Holst et al. (N Engl J Med 2014;371:1381–91) that enrolled 1005 adults in septic shock with an Hb concentration ≤ 9 g/dL recommended the same Hb threshold (7 g/dL). The gaps in 2021 between the expected proportion of respondents who should have chosen a Hb threshold of 7.0 g/dL (100%) and the proportion who chose a higher Hb threshold remained important in 2021.

**Reference 1:** Laverdière C, Gauvin F, Hébert PC, Infante-Rivard C, Hume H, Toledano BJ, et al. Survey of transfusion practices in pediatric intensive care units. Pediatr Crit Care Med 2002;3:335–40.

**Reference 2:** Du Pont-Thibodeau G, Tucci M, Ducruet T, Lacroix J. Survey on stated transfusion practices in PICU. Pediatr Crit Care Med 2014;15:409–16.

**Compliance with ethics regulations:** Yes in clinical research.

<figure><img src="image_43.png" /></figure>

Trajectory of the stated practice pattern of pediatric intensivists on the Hb concentration that would prompt them to prescribe an RBC transfusion in cases of pediatric trauma, septic shock and post Fallot repair, taking into account 3 RCTs (arrows).

### FC-008

#### Visiting policies and parental presence in care: a survey in French Pediatric Intensive Care Units

MANON Bergerat¹, DE SAINT BLANQUAT Laure¹, BERANGER Agathe¹

¹Necker enfants malades, Paris, France

**Correspondence:** Agathe BERANGER (agathe.beranger@gmail.com)

Annals of Intensive Care 2022, **12**(1):FC-008

**Rationale:** The European charter of the hospitalized child recommends a 24-h presence of parents at the bedside. Despite major changes in the last decade, family presence in Pediatric Intensive Care Units (PICUs) still remain controversial within and across countries. The objective of this study was to describe the visiting policies and the parental presence during care in French PICUs.

**Patients and methods/Materials and methods:** A structured questionnaire was emailed to the 35 French PICUs. Data regarding visiting
policies, involvement in care, evolution of policies and general characteristics were collected from April 2021 to May 2021. Descriptive analysis were conducted.

**Results:** Response rate was 80% with 28 PICUs included. A 24-h access for parents was available for all PICUs (n=28) with many facilities. Other authorized visitors were principally grandparents (n=20, 71%) and siblings (n=18, 64%) with a professional support. Number of visitors at the same time was mainly restricted to two visitors in 82% (n=23) PICUs. Family presence was always permitted during medical rounds for 19 (68%) PICUs and sometimes authorized during cardiopulmonary resuscitation for 8 (29%) PICUs. Most of the units never included parents during invasive procedures.

**Conclusion:** An unrestricted access at any time for both parents was found. Restriction regarding type and number of persons at bedside were still applied. Parental presence during care were heterogenous and still restricted. National guidelines and educational programs are needed to support family wishes and promote acceptance by health-care providers.

**Compliance with ethics regulations:** N/A.

## FC-009

### Impact of hyperglycemia on critically ill COVID-19 patient outcomes

ALILA Ilef¹, KHARRAT Sana¹, HADDED Amina¹, JERBI Salma¹, BACCOUCH Najeh¹, BAHLOUL Mabrouk¹, BOUAZIZ Mounir¹

¹hospital Habib Bourguiba Sfax, Sfax, Tunisie

**Correspondence:** Ilef ALILA (ilefalila1323@gmail.com)

*Annals of Intensive Care* 2022, **12**(1):FC-009

**Rationale:** Diabetes is a known risk factor for mortality in Coronavirus disease 19 (COVID-19) patient. Our objective was to identify prevalence of hyperglycemia in COVID-19 patients and its effect on patient outcomes.

**Patients and methods/Materials and methods:** We conducted a retrospective study including critically ill patients with confirmed SARS-COV2 infection in an intensive care unit in between September 2020 and December 2021.

**Results:** During the study period, 586 patients were included with a mean age of 59.5 ± 14.7 years and a sex ratio of 1.6. The median SAPS II and SOFA score were respectively of 29 ± 14.8 and 4 ± 2.6. Most patients had comorbidities, including hypertension (36%), obesity (32.1%) and diabetes mellitus (36.2%). The mean rate of serum glucose on admission was 12.5 ± 6.5 mmol/l. Hyperglycemia occurred in 225 (38.4%) patients; 66 of these hyperglycemic patients (29.3%) had no prior history of diabetes. The mean PH and the mean HCO3- at admission were significantly lower in patients with hyperglycemia (7.37 ± 0.1 vs. 7.41 ± 0.08; p < 0.001 and 22.7 ± 5.6 vs. 23.8 ± 4.7; p = 0.014 respectively). The use of invasive mechanical ventilation was significantly higher in patient with hyperglycemia (p = 0.002). The rate of bacterial infections and the length of stay were not significantly different between patients developing hyperglycemia or not. Mortality was significantly higher in patients developing hyperglycemia during hospitalization (58.2% versus 43% p < 0.001; OR = 1.8[1.3–2.5]).

**Conclusion:** Hyperglycemia without prior diabetes was common and was associated with an increased use of invasive mechanical ventilation and a higher risk of death.

**Compliance with ethics regulations:** Yes in clinical research.

## FC-010

### Cortisol serum level prediction of outcome in critically ill COVID-19 patients

HADDED Amina¹, ALILA Ilef¹, BEN KHALIFA Atraa¹, KHARRAT Sana¹, BACCOUCH Najeh¹, BAHLOUL Mabrouk¹, BOUAZIZ Mounir¹

¹hospital Habib Bourguiba Sfax, Sfax, Tunisie

**Correspondence:** Ilef ALILA (ilefalila1323@gmail.com)

*Annals of Intensive Care* 2022, **12**(1):FC-010

**Rationale:** The COVID-19 epidemic has been a health threat worldwide causing multi-organ damage. However, the endocrine system

and especially cortisol level has been less studied in this pathology. The aim of this study was to explore the role of cortisolaemia in the prediction of outcome in critically ill COVID-19 patients.

**Patients and methods/Materials and methods:** We conducted a retrospective study in a medical ICU over a period of 16 months [September 2020–December 2021] including patients with SARS-COV2 infection. Cortisolaemia were measured during the first 24 h of hospitalization.

**Results:** During study period, 132 patients were included with mean age of 62.5 ± 12.7 years, gender ratio of 1.9. The median SAPS II score was 34 ± 14.3 and the median SOFA score was 4 ± 2.4. Most patients had comorbidities, including hypertension (45.5%), obesity (34.8%) and diabetes (37%). Median cortisol level was 71.2 ng/ml with extremes between 5.2 and 643 ng/ml. Severe acute respiratory distress syndrome (ARDS) was diagnosed in 103 (95%) patients, invasive mechanical ventilation was required in 65 (49.2%) of cases and nosocomial infections were diagnosed in 58 (44%). Median ICU length of stay was 7 days ± 6.3 and overall mortality was of 49.2%. Hypocortisolemia was found in 78 (59%) patients. Fifty-seven patients (73%) with cortisol deficiency had severe ARDS versus only 46 (85%) in the group with a normal cortisolaemia (p = 0.325). Twenty-nine patients (37%) with cortisol deficiency required intubation vs 36 (67%) in the normal group; p = 0.001. The occurrence of infections during hospitalization was observed in 30 (38.5%) patients with cortisol deficiency versus 28 (52%) in the other group (p = 0.15). Mortality was observed in 32 patients with cortisol deficiency (41%) versus 33 (61%) in the other group.

**Conclusion:** Cortisol deficiency was frequently observed in our study but it was not associated with poor outcome in critically ill COVID-19 patients.

**Compliance with ethics regulations:** Yes in clinical research.

## FC-011

### Nutrition in critically ill patients: experience of a multidisciplinary improvement quality program

DE KEYSER Aude¹,², MICHEL Bruno¹,², GALERNEAU Louis-Marie¹, LUMALE Sophie¹, FERRAND Benoit¹, CALVINO-GUNTHER Silvia¹, GIROUD Benoit¹, MAHI Lena¹, IMBERT Wendnonga¹, CHAPUIS Claire¹, SCHWEBEL Carole¹

¹Centre Hospitalier Universitaire Grenoble-Alpes, Grenoble, France; ²Cliniques Universitaires Saint-Luc, Bruxelles, Belgique

**Correspondence:** Aude DE KEYSER (aude.dekeyser@saintluc.uclouvain.be)

*Annals of Intensive Care* 2022, **12**(1):FC-011

**Rationale:** Critically ill patients face significant catabolic situations. Nutrition is part of management beside various organ supply. The Intensive Care Unit (ICU) of our 2200-bed tertiary university hospital starts a quality and continuous improvement program for year 2021 targeting artificial nutrition. The objective of the work was to involve healthcare providers in evaluation and improvement of nutrition management in daily ICU practice.

**Patients and methods/Materials and methods:** A multidisciplinary board composed of physicians (3), clinical pharmacists (3), nurses (3), nursing auxiliaries (2), physiotherapists (2) and dietitian (1) was set up in January 2021. A baseline audit was conducted in April 2021 in the entire unit (18 beds) focusing on concordance with current recommendations between prescribed and administered nutritional intakes and traceability of written transmission. The board identified specific areas for quality improvement for each professional category. Impact of implemented measures was evaluated through a second identical audit in February 2022.

**Results:** The audit conducted over 10 days in April 2021 highlighted proper artificial nutrition practices. All included patients (n = 18; 60 ± 15 yo; 92 ± 23 kg; IGS2 48 ± 7) had enteral nutrition (EN) within 48 h of admission. Half of patients had a BMI over 30. Included population mean ICU duration was 11,3 days and nutrition support was lasting for 10,9 days at time of audit. No patients received parenteral nutrition (PN). At observation patients reached an average of 96% of recommended caloric targets with only 14/18 having nutritional objectives achieved at Day-7 of nutritional support. Other