FC-187

**Liver transplantation for critically ill cirrhotic patients: results from the French transplant registry**

ARTZNER Thierry¹, LEGEA Camille², ANTOINE Corinne², JASSERON
Carine², MICHARD Baptiste¹, FAITOT François¹, SCHNEIDER Francis¹,
BACHELLIER Philippe¹, CASTELAIN Vincent¹

¹CHU Strasbourg, Strasbourg, France; ²Agence de la Biomédecine, Saint
Denis, France

**Correspondence:** Baptiste MICHARD (baptiste.michard@chru-strasbourg.fr)

*Annals of Intensive Care* 2022, **12**(1):FC-187

**Rationale:** This study describes the population of cirrhotic patients who were transplanted from the ICU in France. It identifies pre-transplant risk factors of post-transplant mortality and describes geographic variations in ICU transplant activity.

**Patients and methods/Materials and methods:** Cirrhotic patients transplanted between 2008 and 2018 were included through the national transplant registry. The demographic, clinical and biological characteristics of the patients transplanted from the ICU were compared to cirrhotic patients who were transplanted from home or from the hospital. Risk factors of post-transplant one-year mortality were identified in uni- and multivariable analysis within the population transplanted from the ICU. Funnel plots were used to illustrate center-specific differences in ICU transplant activity.

**Results:** 1,047 cirrhotic patients were transplanted from the ICU during the study period. While the national rate of transplants performed from the ICU was 14.3%, the absolute number and the proportion of cirrhotic patients transplanted from the ICU varied significantly from one center to another, ranging from 6.6% to 22.8% (p < 0.05) (cf. figure). The one-year post-LT survival rate for cirrhotic patients transplanted from the ICU was significantly lower compared to cirrhotic patients transplanted from the hospital and from home (77.1% vs 88.0% vs 89.8% respectively, p < 0.0001). Three recipient associated independent risk factors of one-year post-LT mortality were identified in the population transplanted from the ICU: age > 50 years (HR 1.65, 95%CI 1.16–2.36), p = 0.005), diabetes (HR 1.46, 95%CI 1.07–1.98, p = 0.02) and intubation (HR2.12, 95%CI 1.62–2.78), p < 0.001). Donor age was also independently associated with mortality (HR 1.01, 95%CI 1.01–1.02, p < 0.001).

**Conclusion:** This study underlines the increased post-transplant mortality among cirrhotic patients transplanted from the ICU. It identifies four clinically pertinent independent risk factors associated with post-transplant mortality in this specific sub-group of transplant candidates. Finally, it illustrates how diverse the landscape of liver transplantation for critically ill cirrhotic patients is across a single country, despite a unified allocation algorithm.

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

FC-188

**Pretransplant intensive care unit management and selection of grade 3 acute-on-chronic liver failure transplant candidates**

MICHARD Baptiste¹, ARTZNER Thierry¹, DERIDDER Mathilde¹, BESCH
Camille¹, ADDEO Pietro¹, CASTELAIN Vincent¹, GUILLOT Max¹, LEROUX
Justine¹, HERBRECHT Jean Etienne¹, JANSSEN LANGENSTEIN Ralph¹,
SCHENCK Maleka¹, BACHELLIER Philippe¹, SCHNEIDER Francis¹, FAITOT
François¹

¹CHU Strasbourg, Strasbourg, France

**Correspondence:** Baptiste MICHARD (baptiste.michard@chru-strasbourg.fr)

*Annals of Intensive Care* 2022, **12**(1):FC-188

**Rationale:** The aim of this study is to report on the liver transplant (LT) activity and post-LT outcome over time of grade 3 acute-on-chronic liver failure (ACLF3) patients in the largest single center cohort of patients transplanted with ACLF3 published in the literature. It aims at showing how pre-LT intensive care unit (ICU) management impacts post-LT outcome, in particular through monitoring the transplantation for ACLF3 model (TAM) score, which is based on the recipient's age, arterial lactate level, white blood cell count and respiratory status.

**Patients and methods/Materials and methods:** 100 consecutive patients who had ACLF3 at the time of liver transplant between 2007 et 2019 were included retrospectively. The cohort was divided in 2 periods, with 50 patients in each period.

**Results:** There was a sharp increase in the number of ACLF3 patients transplanted over the course of the study period (from 4.2 to 12.4 patients transplanted with ACLF3 per year), and significantly higher one-year post-LT survival in the second period compared to the first period (respectively 86% vs 66%, p = 0.035). Interestingly, patients during both periods had similar severity profiles and scores, apart from a significantly lower number of patients with TAM scores > 2 at the time of LT in the second period compared to the first period. In addition, patients whose clinical condition improved in the ICU (with a TAM score being downstaged between admission and LT) had significantly higher post-LT survival rates than those whose TAM score stayed the same or increased: respectively 88% vs. 70% (p = 0.042). Finally, the predictive power of the TAM score increased as critically ill cirrhotic patients were closer to the time of LT (cf. figure). In particular, the TAM score was most predictive immediately prior to LT (at the time of organ proposal), with significantly higher survival rates for patients with TAM score 0–2 vs. TAM score > 2: respectively 85% vs. 8% (p < 0.0001).

**Conclusion:** This study shows a learning curve in LT for ACLF3 patients, with optimized ICU management and patient selection leading to increased numbers of LTs for ACLF3 patients and improved post-LT outcomes. It delineates how the TAM score can be used in practice to identify the optimal transplantability window for ACLF3 patients. It shows that the decision to transplant candidate with ACLF3 should not be made prematurely close to ICU admission but rather at the time of organ proposal and that patients whose clinical state improves in the ICU have better post-LT survival.

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

FC-189

**Predictors of early mortality after liver transplantation for acute liver failure**

MOULIADE Charlotte¹,²,³, SACLEUX Sophie-Caroline¹,²,³, ORDAN
Marie-Amélie¹, BOUDON Marc¹,²,³, COILLY Audrey¹,²,³, CAILLEZ Valerie¹,²,³,
SAMUEL Didier¹,²,³, SALIBA Faouzi¹,²,³, ICHAI Philippe¹,²,³

¹AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, Liver Intensive Care Unit, Villejuif, France; ²INSERM Unité 1193, Université Paris-Saclay, Villejuif, France; ³DHU Hepatinov, Villejuif, France

**Correspondence:** Charlotte MOULIADE (charlotte.mouliade@gmail.com)

*Annals of Intensive Care* 2022, **12**(1):FC-189

**Rationale:** After liver transplantation for acute liver failure (ALF), the majority of deaths occur early, in the days and weeks after surgery, due to organ dysfunctions or failures at the time of transplantation.

**Patients and methods/Materials and methods:** Between 2010 and 2021, 105 consecutive patients (62 women, 43 men, mean age 41.5 years) from a single center, with ALF registered for emergency liver transplantation were studied. Epidemiological, clinical, biological and radiological characteristics were collected upon admission, at registration on the transplant list and at the time of transplantation. The objective was to determine the predictive factors associated with 7-day mortality following the liver transplantation.

**Results:** The cause of ALF was paracetamol in 42 patients and non paracetamol in 63. Ninety-eight (93.3%) patients presented hepatic encephalopathy. Mean PT at admission was 17%. The mean SAPS 2 and SOFA scores were 45.4 and 9.8 respectively. All fulfilled the criteria for liver transplantation (King's college and/or Clichy-Villejuif criteria). At registration for the liver transplant, 53 patients (50.5%) were treated with renal replacement therapy, 44 (41.9%) received vasopressor support, and 72 (68.6%) were on mechanical ventilation. Sixty-four patients were transplanted, 15 died prior to liver transplantation and 26 improved without liver transplantation. Eight patients died following liver transplantation. The main causes of death were: multi-organ failure (60.9%), brain death (26.1%), ARDS (8.7%) and ventricular fibrillation (4.3%). Among these patients, 6 died within 7 days of transplantation and 2 after 8 days. The predictors of early mortality (day 7) at the
time of transplantation in univariate analysis were: anuria (p = 0.018), low pH (p = 0.038), low bicarbonate level (p = 0.0006) and high lactate level (p = 0.01). Three events occurring before liver transplantation were associated with an increased risk of early mortality: cardiopulmonary arrest, total hepatectomy with portocaval anastomosis for toxic liver and extensive digestive ischemia. An increase in catecholamine doses was also associated with early mortality, although this association was not statistically significant.

**Conclusion:** This single-center study made it possible to highlight several predictive factors of early mortality after liver transplantation for ALF. The sample size was the main limitation of this study, and a multi-center study is needed to determine independent risk factors.

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

## FC-190

### Gut microbiota composition but not? diversity is linked to subsequent occurrence of ventilator-associated pneumonia in critically ill patients

ORIEUX Arthur¹, ENAUD Raphaël¹, IMBERT Sébastien¹, BOYER Philippe¹, BEGOT Erwan¹, CAMINO Adrian¹, BOYER Alexandre¹, BERGER Patrick¹, GRUSON Didier¹, DELHAES Laurence¹, PRÉVEL Renaud¹
¹CHU Bordeaux, Bordeaux, France

**Correspondence:** Renaud PRÉVEL (renaud.prevel@hotmail.fr)

Annals of Intensive Care 2022, **12**(1):FC-190

**Rationale:** Ventilator-associated pneumonia (VAP) is the most frequent nosocomial infection in critically ill ventilated patients carrying high morbidity and an increase in healthcare costs. Oro-pharyngeal and lung microbiota have been demonstrated to be associated with VAP occurrence but gut microbiota involvement has not been investigated so far despite the relevance of the gut-lung axis in human health and diseases. The aim of this study is thus to compare the composition of the gut microbiota between patients who will subsequently develop VAP and those who will not.

**Patients and methods/Materials and methods:** A rectal swab was performed for routine faecal ESBL-E carriage screening at admission of every consecutive patient into intensive care unit (ICU) from October 2019 to March 2020. After DNA extraction, V3-V4 and ITS2 regions were amplified by PCR. Deep-sequencing was performed on MiSeq sequencer (Illumina®); data were analysed using DADA2 pipeline.

**Results:** Among 255 patients screened, 42 (16%) patients with invasive mechanical ventilation for more than 48 h were included, 18 (43%) with definite VAP and 24 without (57%). Patients with subsequent VAP had similar gut bacteriobiota and mycobiota α-diversities than those who will not develop VAP but gut mycobiota was dissimilar between those 2 groups. The presence of Megasphaera massiliensis was associated with the absence of VAP occurrence whereas the presence of *Bifidobacterium breve*, *Peptostreptococcus anaerobius*, *Enterococcus avium*, *Alternaria* sp. and *Saccharomyces kudriavzevii* was associated with subsequent VAP.

**Conclusion:** The composition of the gut microbiota, but not α diversity, differs between critically ill patients who will subsequently develop VAP and those who will not. This study encourages for large multicentre cohort study investigating the role of gut-lung axis and oro-pharyngeal colonization in the development of VAP in ICU patients and identify potential probiotic candidates for tailored prevention of VAP.

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

## FC-191

### Decontamination regimen and MDR environmental contamination: a sink survey

MASSART Nicolas¹, DUPIN Clarisse¹, MARIE Veronique¹, BARBAROT Nicolas¹, LEGAY Francois¹, FILLATRE Pierre¹
¹CH Saint-Brieuc, Saint-Brieuc, France

**Correspondence:** Nicola MASSART (nicolasmassart@hotmail.fr)

Annals of Intensive Care 2022, **12**(1):FC-191

**Rationale:** Despite a large number of scientific data supporting clinical benefit of selective decontamination in ICU patients with a

decreased risk of multi-drug resistant micro-organisms acquisition. data regarding environmental impact are scarce. We aim to provide a better knowledge on the relationship between decontamination regimens and environmental contamination.

**Patients and methods/Materials and methods:** We conducted an observational analysis in a 14 beds French polyvalent ICU in Saint-Brieuc, Bretagne, France. As of 05th of May 2021, patients with expected mechanical ventilation duration over 24 h received multiple site decontamination (MSD) regimen. MSD is a variant of selective digestive decontamination that included topical antibiotics (gentamycin, polymyxin and amphotericin B) 4 times daily in the oropharynx and the gastric tub, without systemic antibiotic, in addition with a daily 4% chlorhexidine bodywash and a 5-day intra nasal mupirocin course. Two-point prevalence study of sink contamination was performed on June 26th 2020 (pre-implementation) and October 20th 2021 (post-implementation) in the 24 sinks of the unit, at least 48 hours after last disinfection procedure.

**Results:** Samples from the pre-implementation period showed a higher rate of ESBL-PE with 12 sinks (50%) positive for 13 extended spectrum betalactamase producing enterobateriaceae (ESBL-PE) specimens as compared with 4 sinks (17%) containing 4 ESBL-PE during post-implementation period (Macnemar paired test = 0.043). Conversely, the number of positive samples for imipenem resistant Pseudomonas aeruginosa (IRPA) increased 1 (4%) and 8 (33%) positive sinks in the pre and post-implementation periods respectively (Macnemar paired test = 0.046) (Figure). Of note, there were 11 Pseudomonas aeruginosa infections and 1 ESBL-PE infection during 6 months pre-implementation (3112 patients-days) as compared with 2 Pseudomonas aeruginosa and 1 ESBL-PE infections in the 6 months post-implementation (2196 patients-days) (p = 1 for ESBL-PE infections and p = 0.023 for PA, poisson regression test).

**Discussion:** Previous studies already reported a diminution of colonization with Gram-negative resistant bacteria in patients receiving decontamination regimens. Decrease in ESBL-PE sink colonization may be secondary to a decrease of patient-to-sink ESBL-PE transmission. Despite a diminution in the incidence of Pseudomonas aeruginosa infections between both periods, there are concerns regarding the increased in IRPA in the sinks. A study previously suggested that exposure to common disinfectant leads to expression of outer membrane protein OprR, giving potential resistance to carbapenems.

**Conclusion:** In conclusion, we described for the first time a diminution of ESBL-PE but an increased in IRPA sink contamination with MSD regimens including topical antibiotic and chlorhexidine body wash.

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

<figure><img src="image_96.png" /><figcaption>Figure. ICU maps</figcaption></figure>

## FC-192

### Echocardiography in the Time of COVID-19.

SDIRI Ines¹, FITOUHI Nizar¹, DRIDI Amira¹, LAROUI Sana¹, OUERGHI Sonia¹, MESTIRI Tahar¹

¹H'Hôpital Ariana Abderahmen Memi, Sfax, Tunisie

**Correspondence:** Ines SDIRI (sdiri.ynes@gmail.com)

Annals of Intensive Care 2022, **12**(1):FC-192
**Rationale:** Many published studies during the Covid-19 pandemic have focused on the respiratory component and their management while the hemodynamic component has had a major impact (1). Despite the important incidence of cardiac complications, few studies have reported the place of echocardiography in Covid-19 patients (2). Our study aimed to report the echocardiographic findings in severe covid-19 patients.

**Patients and methods/Materials and methods:** This is a retrospective descriptive study conducted at the medical intensive care unit of circumstance Hospital, between January 1, 2021 and December 31, 2021. Were included the confirmed covid-19 patients of severe form and having benefited from an echocardiography at admission. An evaluation of the left ventricular function, the right one, the filling pressures, the valves and the pericardium.

**Results:** 300 results were collected. Mean age was 57 years, 53.6% male. The BMI was 30.84. Comorbidities were hypertension 37.3%, diabetes 33.1% and cardiovascular pathologies 14%. The mean PaO2/FiO2 ratio was 123 and the CT scan injury was 71.12%. The use of mechanical ventilation was 57.7% and catecholamines 62.8%. The average length of stay was 10 ± 8 days. The incidence of thrombi-embolic events was 22.1%. Mortality was 45%. Cardiac ultrasound was totally transthoracic. LV ejection function was impaired in 20.8% (< 50% in women and < 55% in men). Septal hyperkinesia was observed in 4% revealing ACS. 3% had acute pulmonary heart disease as evidenced by the presence of a paradoxical septum. 31.6% had relaxation disorders and 1% had compliance disorders. The evaluation of the filling pressures was in the gray zone for 33.7% and 2% elevated. The patients were mostly in hypovolemia 78.6% objectified by an inferior vena cava diameter lower than 15 cm. PAH was found in 10% of cases. Valvulopathies were present in 10.9%, dominated by mitral insufficiency 42% and tricuspid insufficiency 58% minimal justified by ARDS. Pericardial effusion was found in 13.9%, of minimal to moderate abundance.

**Conclusion:** Our study underlines the contribution of cardiac ultrasound in severe covid-19 to detect cardiac complications, the reperfusion of ARDS in the hemodynamics and to guide the adequate management.

**Reference 1:** J Am Soc Echocardiogr. août 2020;33(8).

**Reference 2:** J Am Coll Cardiol. 19 janv 2021;77(2).

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

## FC-193

### The contribution of Tocilizumab in treatment of patients with a SARS-COV2 infection

BOUCHECH Bouthaina¹, CHTOUROU Ameni¹, DAMMAK Rania¹, KOLSI Hichem², DERBEL Rahma¹, BEN OMOR Oumaima²

¹Hôpital Habib Bourguiba, Sfax, Tunisie; ²Hôpital de campagne Slim Chaker, Sfax, Tunisie

**Correspondence:** Bouthaina BOUCHECH (bouthainasellami@gmail.com)

*Annals of Intensive Care* 2022, **12**(1):FC-193

**Rationale:** SARS-COV2 virus is responsible for hypoxemic pneumonia that can evolve into an acute respiratory distress syndrome The Tocilizumab is indicated in the treatment of severe syndromes caused by cytokine release induced by CAR-T lymphocytes and therefore the objective of this study is to determine the contribution of this molecule in the treatment of critical patients infected with SARS-COV2.

**Patients and methods/Materials and methods:** it is a descriptive retrospective study including 20 patients hospitalized in an intensive care unit for a SARS-COV2 pneumonia during the period extending from March 2021 to October 2021. These patients have received 2 doses of Tocilizumab equivalent to 8 mg per kg within an interval of 48 h between the two doses. The inclusion criteria are patients with an elevated level of IL6 (superior to 7 pg/ml), hospitalized in an intensive care unit, under high oxygen flows (superior to 10 l/min). The exclusion criteria are the presence of a bacterial infection, hepatocellular failure, thrombocytopenia, pregnancy and intubated patients.

**Results:** our study included 20 patients with an age average of 56 years and a sex ratio of 1.16. These patients are classified ASAI1 at minimum. All patients were under corticosteroid therapy .16 patients

had a thoracic scan revealing a lung damage extended on 25% to 50%. During their stay in the ICU, all of these patients presented with a respiratory deterioration between the third and 22nd day of evolution. 80% of patients were under either a high flow oxygen or high concentration mask and 20% were under a non-invasive ventilation. Before the administration of the cure, their level of IL6 was between 12 and 107 pg/ml, the level of AST was between 18 and 76 IU/L and the level of AIT was between 12 and 73 IU/L. The treatment was administered between day 5 and day 19 The complications induced by the treatment were a respiratory deterioration in 80% of the cases, a nosocomial infection in 15%, hepatic cytolysis in 10%, and anaphylactic choc in 5% After a week, 30% of patients were out of the ICU and put under oxygen with a flow between 6 and 15 l/min while 70% were still under mechanical ventilation.

**Conclusion:** In Tunisia the number of reported cases is still low. However, it is essential to conduct further clinical trials to evaluate the efficiency as well as the timing of administration of Tocilizumab in relation to the beginning of symptoms especially that this treatment is not risk free.

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

## FC-194

### Dexamethasone or methylprednisolone therapy in covid-19 pneumonia: a retrospective and comparative study of 513 cases

EL MEZZEOUI Sanae¹, BEN CHAIB Rajae¹, HOUSNI Brahim¹, BKIYER Houssam¹.

¹centre hospitalier mohammed V oujda, Oujda, Maroc.

**Correspondence:** Sanae EL MEZZEOUI (sanae.elmezzeoui@gmail.com)

*Annals of Intensive Care* 2022, **12**(1):FC-194

**Rationale:** Corona virus disease 19 (Covid-19) affects especially the respiratory tract, and induces lung injury which may progress to the acute respiratory distress syndrome (ARDS). Various treatment options were tried all over the world, corticosteroids had showed beneficial effects. The Objective of this study, is to compare the safety and efficiency of two corticosteroids: dexamethasone and prednisolone in the treatment of Covid-19 infection.

**Patients and methods/Materials and methods:** This retrospective and comparative study included 513 patients diagnosed with Covid-19 infection and were admitted to intensive care unit of our university hospital center of MOHAMMED VI Oujda from March 1, 2020, to December 31st, 2020.

**Results:** In this study, 513 cases were included, 230 patients received methylprednisolone, and 283 were treated with dexamethasone. The median age in methylprednisolone group was 64 years, and 63 years in the second group treated with dexamethasone. Patients treated with dexamethasone had more critically lesions compared to patients treated with methylprednisolone (67.6%), these patients had a good evolution with a significant reduction of oxygen supplementation, lower use of invasive ventilation and a significant improvement in biological parameters. The difference in outcome between the two groups in terms of mortality was significantly reduced in the second group.

**Conclusion:** Both steroids are efficient in the management of mild, moderate and severe Covid-19 pneumonia with a clear superiority of dexamethasone especially in severe forms.

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

## FC-195

### Prediction of ICU mortality in critically ill patients with COVID-19

TRIFI Ahlem¹, CHERIF Hichem², SEGHIR Eya¹, JERIBI Badis², ABDENNEBI Cyrine¹, MASSEOUDI Yosri², ABDELLATIF Sami¹, AMMOUS Adel², BEN LAKHAL Salah¹

¹Medical ICU, la Rabta hospital, Faculty of Medicine of Tunis, Tunis, Tunisie;

²Department of anesthesia, la Rabta hospital, Faculty of Medicine of Tunis, Tunis, Tunisie

**Correspondence:** Ahlem TRIFI (trifiahlem2@gmail.com)

*Annals of Intensive Care* 2022, **12**(1):FC-195
**Rationale:** COVID-19 pandemic has rapidly required an increased number of ICU admission and deaths. In view of this alarming situation, it became mandatory to develop prognostic models to evaluate critical COVID-19 patients. We aimed to study the characteristics and prognosis of adult patients with critical COVID-19 requiring hospitalization in ICU during 2nd, 3rd and 4th waves of the pandemic in order to identify the predictive factors of mortality.

**Patients and methods/Materials and methods:** We retrospectively evaluated a cohort of consecutive COVID-19 critically ill patients admitted to ICU with a confirmed diagnosis of SARS-CoV-2 pneumonia. A multivariable regression model including demographic, clinical and laboratory findings was developed to assess the predictive value mortality of these variables using the ROC curves. Our main outcome was ICU mortality.

**Results:** 358 were included (genre-ratio = 1.75, mean age = 60 ± 13 years, median BMI = 27.7 kg/m² and SOFA = 4 [3–6]). The most observed age class was 60–79 and 44% were obese. 72 (20%) had no comorbidities. Arterial hypertension (40.2%) and diabetes (39.1%) were the most reported co-morbidities. The median time of respiratory distress from the symptomatology onset was 11 days [8–15]. Clinical signs were: dyspnea (94%), fever (72.6%) and cough (70.4%). The median P/F ratio was 90 [67–129.5] and 58.5% of patients were in severe ARDS. In 45% of cases, ground-glass opacities exceeded 50% in the chest CT. 218 patients (61%) required mechanical ventilation (MV) and among them 12 (5.5%) were successfully weaned. The most complications were shock (49%), acute kidney injury (31%) and ICU related infection (34%). The evolution was fatal in 64% of cases (n = 229). In Multivariable Model: Tachycardia (HR > 99 bpm), an initial P/F ratio < 107 and MV were the factors independently associated to mortality with respectively OR [95% CI] at 39.9 [1.2–1307], 424 [2,23–80560] and 2235 [2,74–181842]. Other factors tended to the significance: SOFA > 3.5 (OR = 292 [0.9–9715], p = 0.055), a lymphocyte count < 555 el/mm³ (OR = 92.3 [0.84–1073], p = 0.059) and occurrence of shock (OR = 119 [0.99–15679], p = 0.055). The most predictive death factors were the use of MV (AUC/ROC = 0.904 [0.866–0.941], p < 10–3, Se = 90% and Sp = 90.7%) and shock (AUC/ROC = 0.854 [0.814–0.895], p < 10–3 and Sp = 96.2%). The other variables had significant AUC/ROC but a low predictivity (table).

**Conclusion:** in our large series, independent factors of mortality were a deep hypoxemia, tachycardia, mechanical ventilation, and with a trend to a significance shock, presence of more than 3 organ dysfunctions and lymphopenia. The highly predictive death factors were MV and Shock.

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

<table><caption>Table. Predictive performance of mortality factors</caption><thead><tr><th></th><th>AUC/<br>ROC</th><th>95% CI</th><th>p</th><th>Se (%)</th><th>Sp (%)</th></tr></thead><tbody><tr><td>MV</td><td>0.904</td><td>[0.866-0.941]</td><td>&lt;10<sup>3</sup></td><td>90</td><td>90.7</td></tr><tr><td>Shock</td><td>0.854</td><td>[0.814-0.895]</td><td>&lt;10<sup>3</sup></td><td>74</td><td>96.2</td></tr><tr><td>SOFA&gt;3.5</td><td>0.708</td><td>[0.648-0.768]</td><td>&lt;10<sup>3</sup></td><td>86.4</td><td>55.8</td></tr><tr><td>Initial P/F &lt; 107</td><td>0.656</td><td>[0.595-0.717]</td><td>&lt;10<sup>3</sup></td><td>73.7</td><td>59</td></tr><tr><td>Tachycardia (HR&gt;99 bpm)</td><td>0.610</td><td>[0.550-0.671]</td><td>0.001</td><td>44</td><td>77.5</td></tr><tr><td>Lymphopenia (&lt;555 el/mm<sup>3</sup>)</td><td>0.579</td><td>[0.519-0.640]</td><td>0.014</td><td>34</td><td>83</td></tr></tbody></table>

MV: mechanical ventilation, SOFA: Sequential Organ Failure Assessment, HR: heart rate

### Predictive performance of mortality factors

#### FC-196

##### Characterization of patients who return to Emergency department following discharge from hospitalization for COVID-19

JERBI Mouna¹, GHORBEL Rezk¹, GHARBI Emna¹, SNOUSSI Haifa¹, AFFES Lobna¹, KESENTINI Bouthaina¹, CHAKROUN Olfa¹, REKIK Noureddine¹

¹Centre Hospitalo-universitaire Habib Bourguiba fax, Sfax, Tunisie

**Correspondence:** Rezk GHORBEL (rezkghorbel3@gmail.com)

Annals of Intensive Care 2022, **12**(1):FC-196

**Rationale:** To describe the specific epidemiological profile of post-COVID patients consulting in the emergency ward, the characteristics of the infectious episode, these repercussions on daily life as well as data concerning the symptoms, the problems and the reasons for consulting.

**Patients and methods/Materials and methods:** This is a descriptive prospective study collecting post-COVID patients, who presented to the medical emergency ward, regarding age and reason for consulting during the period from 1 June to 30 August 2021.

**Results:** 111 patients returned for emergency care after a median period of 8 ± 2 days, with 32.4% requiring readmission. Mean age was 54 ± 18 years, 42.9% men. Their chronic medical conditions included hypertension 25 (22.5%), diabetes mellitus 26 (23.4%) and coronary artery disease 4 (3.6%). The reasons for consulting the emergency ward, were mainly represented by exacerbation of dyspnea (39%). Main reasons for readmission were acute respiratory failure (25.2%), chest pain (25.2%). The rate of arterial or venous thromboembolic complications in COVID-19 patients was (21%). Among patients readmitted to the hospital 4% were hospitalized in intensive care unit.

**Conclusion:** The follow-up of post-COVID patients is very interesting. It makes it possible to identify different problems that can be classified as acute complication or a post-COVID syndrome, including respiratory failure. It requires monitoring and multidisciplinary care involving many specialties.

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

#### FC-197

##### Vaccination against COVID-19: knowledge and perception of healthcare givers working in COVID sectors

TRIFI Ahlem¹, MEHDI Asma¹, MASSEOUD Lynda¹, MEFTEH Amal¹, SEGHIR Eya¹, ABID Emna¹, ABDENNEBI Cyrine¹, ABDELLATIF Sami¹, BEN LAKHAL Salah¹

¹Medical ICU, la Rabta hospital, Faculty of Medicine of Tunis, Tunis, Tunisie

**Correspondence:** Ahlem TRIFI (trifiahlem2@gmail.com)

Annals of Intensive Care 2022, **12**(1):FC-197

**Rationale:** The generalization of vaccination against SARS-CoV-2 is one of the pillars of the strategy to fight against the virus spread and limit the morbidity and mortality. In this context, the role of caregivers is paramount by being a frequently requested source for information and influence. OBJECTIVE: To assess the knowledge and perception of healthcare givers (HCG) working in COVID sectors regarding the SARS-CoV-2 vaccine.

**Patients and methods/Materials and methods:** Online survey targeting HCG working in the COVID sectors of Tunisia. The questionnaire was created on the Google-Forms platform exploring 3 sections: personal data, knowledge and perceptions about vaccination.

**Results:** 282 HCG responded to the questionnaire. The majority were medical physicians (199 (70.5%) including seniors (n = 106). The age range of 18–39 years was predominant (68%) and the sex ratio (M/F) = 0.35. Medical HCG exercised in university hospitals in 230 cases, private (n = 15) and regional (n = 37) and intensive care accounted for 43% of the nature of COVID activity. Half (48%) contracted the virus SARS-CoV-2 and the clinical form was considered minor in 82% of cases and severe requiring resuscitation in 5 cases. 87% received their full dose and 45% were within 3–6 months of the 2nd dose. Pfizer-Biontech (48%), Sputnik (34%) and Chinese vaccines (13%) were the most received. As for knowledge and opinions, there was a discrepancy between the medical and paramedical HCG: the second category was less convinced by the vaccination, recommended the vaccine less to their advice seekers, believed less that immunity would be better acquired by the disease than by the vaccine and had less confidence in science in the development of the anti-SARS-CoV vaccine. Twenty-five (9%) of the responders considered themselves to be anti-vaccine (medical HCG: 4 and paramedical HCG: 21) and the main reason was the lack of information about vaccines.
**Conclusion:** The existing perception and attitude of frontline health workers differ depending on medical or paramedical status. Motivation and positive influence were felt less by the second population. Measures are essential to minimize these gaps: more awareness programs adapt communication strategies, obligations? ...

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

FC-198

Mental health of intensive care professionals more than a year after the first peak of the health crisis

FOURNIER Alicia¹, DELTOUR Victoire¹,², LHEUREUX Florent³, ECARNOT
Fiona⁴, BINQUET Christine⁵,⁶, QUENOT Jean Pierre⁵,⁷,⁸,⁹, LAURENT
Alexandra¹

¹Laboratoire Psy-DREPI, Université de Bourgogne, Dijon, France; ²VCR EA 7403, Ecole de Psychologues Praticiens, ICP, Paris, France; ³Laboratoire de Psychologie, Université de Franche-Comté, Besançon, France; ⁴Département de cardiologie, Université de Franche-Comté, Besançon, France; ⁵INSERM, CIC1432, module Epidémiologie Clinique (CIC-EC), Dijon, France; ⁶CHU Dijon-Bourgogne, UFR des Sciences de Santé, Dijon, France; ⁷Service de Médecine Intensive-Réanimation, CHU Dijon-Bourgogne, Dijon, France; ⁸Equipe Lipness, centre de recherche INSERM UMR1231 et LabEx LipSTIC, Université de Bourgogne, Dijon, France; ⁹Espace de Réflexion Éthique Bourgogne Franche-Comté, Dijon, France

**Correspondence:** Alicia FOURNIER (alicia.fournier@u-bourgogne.fr)

Annals of Intensive Care 2022, **12**(1):FC-198

**Rationale:** The health crisis linked to COVID-19 has significantly changed the organization and the context of care in intensive care units (ICU). New and numerous stressors have been added to the stressors already present in the units (1). One of the specificities of this crisis is notably its duration and its uncertain outcome. In this context, acute and chronic stress have been combined, constituting the risk of developing stress-related disorders that become chronic in ICU professionals. The objective of this paper is to present the psychological impact of the health crisis on intensive care workers 1 year and 2 months after its first peak in France.

**Patients and methods/Materials and methods:** Between 21 June and 19 July 2021, 840 professionals (physicians, residents, nurses, nurses' aides, students, and nursing managers) in 48 French hospitals took part in the PsyCOVID-ICU study. An online questionnaire was administered online via the Limesurvey platform. We assessed the severity of PTSD symptoms (IES-R), burnout (MBI-HSS), perceived stressors (PS-ICU) and the support used to cope with professional stress (colleagues, hierarchy, entourage, hotline, psychologist).

**Results:** The results show that 60.24% of the professionals had burnout. Of these, 16.38% also had possible PTSD. Only 2.4% of the professionals had possible PTSD without burnout. Professionals who suffered from both possible PTSD and burnout perceived significantly more stress than other professionals (ps < 0.002). They were particularly sensitive to the perception of a heavy workload and difficulties related to human resources management. Most of these professionals turned to support from their colleagues and relatives (ps < 0.025) and the least to the hotline (ps < 0.001).

**Conclusion:** This study illustrates the long-term effects of the health crisis on the mental health of intensive care professionals. It highlights a population of ICU professionals who are particularly sensitive to stress in the ICU one year after the crisis and who suffer from post-traumatic stress and burnout.

**Reference 1:** Laurent A., Fournier A., Lheureux F., .... Quenot JP. (2021). Mental health and stress among ICU caregivers in France according to intensity of the COVID-19 epidemic. Annals of intensive care. 4;11(1):90. https://doi.org/10.1186/s13613-021-00880-y.

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

FC-199

Prediction of the location of infectious droplets and aerosols with computational fluid dynamics in the rooms of ICU patients

DE HARENNE Charlotte¹, GAMBALE Alessandro², BOSSE Maxime³, LISSON Maxime⁵, LAMTIRI Mouhsine³, PITTI Pauline³, OBANDO VEGA Pedro⁵, BERTRAND Axelle¹, MAHIANE-BIDJA Anne¹, KESSELER Sophie¹, MEEX Cécile³, HAUBRUGE Eric⁴, SAEGERMAN Claude⁵, DESMECHT Daniel⁶, MISSET Benoît¹

¹Department of Intensive Care Medicine - CHU Liege, Liege, Belgique;

²BUILDWIND SPRL, Brussels, Belgique; ³Department of Microbiology - CHU LIEGE, Liege, Belgique; ⁴Terra Research Center - Gembloux Agrobio-tech - University of Liege, Gembloux, Belgique; ⁵Research Unit in Epidemiology and Risk Analysis - Faculty of Veterinary Medicine - University of Liege, Liege, Belgique; ⁶Department of Pathology - Faculty of Veterinary Medicine - University of Liege, Liege, Belgique

**Correspondence:** Benoît MISSET (benoit.misset@chuliege.be)

Annals of Intensive Care 2022, **12**(1):FC-199

**Rationale:** SARS-CoV 2 is likely transmitted between humans through direct contact and/or infectious droplets and aerosols. Droplets are defined as particles over 5 µm and aerosols as particles less than 5 µm diameter. Our aim was to estimate the location of the particles within a real intensive care room when hosting a patient with COVID-19 and assess the presence of SARS-CoV-2 in these particles.

**Patients and methods/Materials and methods:** We used the architectural features of several individual rooms of our Intensive Care department, the prescribed and measured heating, ventilation, and air-conditioning characteristics. We modeled the air flow and droplet dynamics using Computational Fluid Dynamics. Unsteady RANS, three-dimensional numerical simulations used a k-w SST turbulence model with heat transfer and buoyancy for natural convection. The computational domain included the room ventilation system with piping and vents, air leakage from the doors, and the main objects in the rooms. Air and surface samples for SARS-CoV-2 PCR were guided by the simulation.

**Results:** The measured HVAC characteristics in terms of air flow were different than the prescribed one. Simulations showed that droplets were mostly present on the workbenches and on the floor in front of the door, and that aerosols flew vertically towards the ceiling, stayed in suspension or followed the leakage around the doors. SARS-CoV-2 was searched in the rooms of 9 patients treated with high flow oxygen and nasal Ct between 17 and 31. PCR was positive in 10/25 (40%) surface and 3/15 (20%) air samples where it was expected by simulation, and in 1/5 (20%) surface and 0/12 air samples where it was not expected. Positive surfaces were air-extract units, the floor in front of the door and the nurse workbench. Positive air samples were over the patient's head and in front of the door outside the room. Additional samples are underway to increase the prediction of the computational model.

**Conclusion:** In our institution, the observed HVAC characteristics are different from the prescribed ones. Taking the actual characteristics of the rooms into account and using a numeric 3-D simulation model, the use of a computational model accurately predicts locations where SARS-Cov-2 particles can be found.

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

<figure><img src="image_97.png" /><figcaption>Numeric 3-D simulation model</figcaption></figure>
## FC-200

### Impact of emotional stimulations on thirst in critically ill mechanically ventilated patient

BUREAU Côme¹, SIMILOWSKI Thomas¹, DEMOULE Alexandre¹

¹Hôpital Universitaire Pitié-Salpêtrière, Paris, France

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

Annals of Intensive Care 2022, **12**(1):FC-200

**Rationale:** Up to 70% of intensive care unit patients report thirst. Thirst provokes the urge to drink fluids. This multidimensional symptom is described in terms of intensity and dry mouth. Few studies have investigated thirst relief in intensive care unit patients and none has focused on mechanically ventilated (MV) patients. Relieving thirst usually involves giving the patient something to drink; unfortunately, in this population, it is difficult to meet this need and alternative interventions are needed. Our objective was to evaluate and to compare the impact of auditory and a sensory stimulations on the intensity of thirst in critically ill patients undergoing invasive or non-invasive MV. This is an ancillary study of the "Sensopnea 2" study.

**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 (inclusion criteria of the Sensopnea 2 study). Two visual analog scales (Thirst-VAS and Dry mouth-VAS) assessed thirst and dry mouth sensation. We studied the following interventions: 1) a relaxing standardized music piece vs. a "pink" noise as a control (auditory stimulation), and 2) fresh air directed toward the face vs. the thigh as a control (sensory stimulation). A washout period separated each condition.

**Results:** We included 46 patients, 19 tracheostomized (41%), 18 intubated (39%) and 9 under non-invasive ventilation (20%). Median (interquartile range) age was 63 years (54–73) and duration of mechanical ventilation was 33 days (7–49). Figure 1 shows Thrirst-VAS and Dry mouth-VAS during sensory stimulation and auditory stimulation with their control. Compared to their respective control group, the two interventions decreased Thrirst-VAS: 1) auditory stimulation 20 [0–30] vs. 30 [0–40], p = 0.0004 and 2) sensory stimulation 30 [20–50] vs. 40 [30–50], p = 0.0025). Compared to their respective control group the two interventions decreased Dry mouth-VAS: 1) auditory stimulation 30 [10–40] vs. 40 [30–70], p = 0.0002 and 2) sensory stimulation 30 [0–60] vs. 40 [30–60], p = 0.0013).

**Conclusion:** In critically ill dyspneic MV patients, auditory and sensory stimulations decrease thirst and dry mouth sensation.

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

<figure><img src="image_98.png" /><figcaption>VAS Visual analogue scale **p < 0.01, ***p < 0.001</figcaption></figure>

## FC-201

### Prevalence of low vitamin D level and outcome impact in weaning unit after prolonged stay in ICU

PERETOUT Jean-Baptiste¹, NSSAIR Karim¹, ABDALLAH Razach¹, LEPECQ Raphael¹, DONETTI Laurence¹, LAISSI Mohamed¹, CHOUKROUN Gérald¹

¹Hôpital Forcilles - Fondation Cognacq-Jay, Férolles-Atilly, France

**Correspondence:** Jean-Baptiste PERETOUT (jperetout@cognacq-jay.fr)

Annals of Intensive Care 2022, **12**(1):FC-201

**Rationale:** Recent studies suggest that low vitamin D level is associated with an increased risk of hospitalization, critical care use, enhanced systemic inflammation and mortality¹,². The objective of this study was to determine the prevalence of hypovitaminosis D and vitamin D deficiency in patients hospitalized in a respiratory weaning unit and the impact on weaning outcomes after a prolonged ICU stay.

**Patients and methods/Materials and methods:** This is a prospective, descriptive cohort study of patients hospitalized in respiratory weaning unit after a prolonged ICU stay over the year 2021. Plasma 25-hydroxyvitamin D concentrations ([25(OH)D]) was collected from the 48-h admission blood test. We defined hypovitaminosis D by [25(OH)D] < 30 ng/mL and vitamin D severe deficiency by [25(OH)D] < 10 ng/mL. We also compared the biological data and weaning outcomes of patients with hypovitaminosis D and patients with normal levels.

**Results:** We analyzed 136 patients (mean age 63 ± 12 years; male 70%; COVID 70%) hospitalized in a weaning unit for mechanical ventilation and/or tracheostomy after prolonged stay in the ICU. On admission, the prevalence of hypovitaminosis D was 88.3% (n = 120), the prevalence of severe deficiency was 3.7% (n = 5) and the mean [25(OH)D] was 20.7 ± 7.9 ng/mL. No statistical difference on [25(OH)D] levels was found between patients with successful decannulation and those with failed decannulation: 20.7 ± 8.3 vs 20.7 ± 5.6 ng/mL (p = 0.98). In hypovitaminosis D group, phosphorus was statistically lower than in the other group: 1.08 ± 0.32 vs 1.25 ± 0.27, p = 0.035. No statistical difference was found on weaning outcomes (Table I).

**Conclusion:** The prevalence of hypovitaminosis D is major in weaning unit after a prolonged ICU stay. Among the other biomarkers, only phosphorus is lower in the deficient group probably related to its role in the metabolism of vitamin D. However, vitamin D deficiency does not appear to be a factor influencing weaning's outcomes. Screening and treatment are still necessary in the treatment of long-term complications.

**Reference 1:** Bychinin MV, Klypa TV, Mandel IA, Andreichenko SA, Baklashev VP, Yusubalieva GM, Kolyshkina NA, Troitsky AV. Low Circulating Vitamin D in Intensive Care Unit-Admitted COVID-19 Patients as a Predictor of Negative Outcomes. J Nutr. 2021 Aug 7;151(8):2199–2.

**Reference 2:** Pimentel GD, Dela Vega MCM, Pichard C. Low vitamin D levels and increased neutrophil in patients admitted at ICU with COVID-19. Clin Nutr ESPEN. 2021 Aug;44:466–468.

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

<table><caption>Table I Biomarkers and weaning outcomes in hypovitaminosis D group and normal vitamin D group.</caption><thead><tr><th>Parameters</th><th>25(OH)D &lt; 30 ng/mL (n=120)</th><th>25(OH)D &gt; 30 ng/mL (n=16)</th><th>p-value</th></tr></thead><tbody><tr><td>25(OH)D</td><td>18.5 ± 5.1</td><td>36.9 ± 6.6</td><td>&lt; 0.001</td></tr><tr><td>c-Calcium (mmol/l)</td><td>2.39 ± 0.16</td><td>2.36 ± 0.14</td><td>0.431</td></tr><tr><td>Phosphorus (mmol/l)</td><td>1.08 ± 0.32</td><td>1.25 ± 0.27</td><td>0.035</td></tr><tr><td>Albumin (g/dl)</td><td>29.8 ± 4.6</td><td>31.3 ± 4.3</td><td>0.217</td></tr><tr><td>Prealbumin (g/dl)</td><td>0.19 ± 0.07</td><td>0.22 ± 0.07</td><td>0.087</td></tr><tr><td>Creatinine (μmol/l)</td><td>54.6 ± 48.6</td><td>78 ± 57.7</td><td>0.059</td></tr><tr><td>CRP</td><td>43.8 ± 39.8</td><td>50.4 ± 53.3</td><td>0.524</td></tr><tr><td>WBC (x103/mm3)</td><td>9.95 ± 3.66</td><td>11.17 ± 5.28</td><td>0.209</td></tr><tr><td>NLR</td><td>5.6 ± 4.3</td><td>5.3 ± 4.3</td><td>0.759</td></tr><tr><td>TSH</td><td>3.9 ± 7.4</td><td>4.9 ± 10.6</td><td>0.614</td></tr><tr><td>Age (y)</td><td>62.8 ± 11.7</td><td>67.5 ± 7.7</td><td>0.093</td></tr><tr><td>Length of stay in ICU (d)</td><td>60.1 ± 31.2</td><td>60 ± 34.7</td><td>0.992</td></tr><tr><td>IGS2 in ICU</td><td>44 ± 17</td><td>49 ± 14</td><td>0.616</td></tr><tr><td>Drotracheal intubation duration (d)</td><td>30.5 ± 13.4</td><td>31.6 ± 20</td><td>0.750</td></tr><tr><td>Time to 24 h spontaneous ventilation (d)</td><td>8.8 ± 12.6</td><td>5.9 ± 14.7</td><td>0.388</td></tr><tr><td>Time to decannulation (d)</td><td>20.9 ± 15.5</td><td>17.8 ± 17.8</td><td>0.462</td></tr><tr><td>Length of stay in Weaning Unit (d)</td><td>31 ± 18.8</td><td>28.3 ± 15.9</td><td>0.542</td></tr><tr><td>IGS2 in Weaning Unit</td><td>26 ± 8</td><td>23 ± 6</td><td>0.287</td></tr></tbody></table>

## FC-202

### Impact of time of administration and dose of desmopressin in brain-dead donors: a before-after study

MOLINA Laura¹, GENEIX Mario¹, LE PRINCE Marine¹, MOSCHIETTO Sebastien¹, MONTINI Florent¹

¹Centre hospitalier d'Avignon, Avignon, France

**Correspondence:** Laura MOLINA (molina.laura@hotmail.fr)

Annals of Intensive Care 2022, **12**(1):FC-202

Annals of Intensive Care 2022, **12**(1):FC-202
**Rationale:** Diabetes insipidus is one of the complications of brain death. Its management consists in the introduction of desmopressin. There are no studies focusing on the dosage and timing of desmopressin administration in brain dead organ donors. It's possible that the earliest administration of desmopressin in relation to the diagnosis of central diabetes insipidus and at high doses may influence the hemodynamics of donors, their renal function and recipient in the short and long term. The objective of our study is to compare, after introducing a new protocol in 2018, the modalities of desmopressin administration in terms of time of introduction and dosage and then the impact on hemodynamics, donor renal function, and the impact on renal function of renal transplant recipients.

**Patients and methods/Materials and methods:** We conducted a single center, retrospective study. A total of 196 patients were included, with a diagnosis of brain death, during a period of 6 years. The protocol used during the first period between 2015 and 2017 was, after the diagnosis of diabetes insipidus, the infusion of a bolus of 1 µg of desmopressin, then 1µg every 6 h according to evolution. The new protocol was infusion of a bolus of 2 µg of desmopressin then continuous infusion of 4 µg/24 h, with the possibility of additional boluses. The data on the recipients was sent to us by the biomedicine agency.

**Results:** We found a statistically significant difference in the delay of desmopressin introduction (4H group 2015-2017 vs. 1H group 2018-2020), as well as in the total dosage administered (1 µg 2015-2017 vs. 4 µg 2018-2020). We found a significant difference in the administration of glucose solution (4L group 2015-2017 vs 2.5L group 2018-2020), as well as a significant difference in the dosages of noradrenaline administered (0.2 gamma/kg/min group 2015-2017 vs 0.1 gamma/kg/min group 2018-2020 p = 0.04). We noted higher natremia in the first group, not significant (148 mmol/l group 2015-2017 vs 146 mmol/l group 2018-2020). However, we did not find any differences in the renal functions of the donors or recipients. The number of functional grafts at 1 year was higher in the 2018-2020 group.

**Conclusion:** This study, the first to compare 2 methods of desmopressin administration in brain-dead donors. It shows that increasing dosages and reducing the time of administration is safe, allows better haemodynamic management of donors and may improve long-term renal transplant outcomes.

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

<table><thead><tr><th></th><th>Période 2015-2017<br>N = 83</th><th>Période 2018-2020<br>N = 37</th><th>P value</th></tr></thead><tbody><tr><td>Dernier état connu du greffon<br>(n= 120)</td><td></td><td></td><td>0,050</td></tr><tr><td>Fonctionnel</td><td>57 (68,7%)</td><td>33 (89,2%)</td><td>0,022</td></tr><tr><td>Non-fonctionnel</td><td>11 (13,3%)</td><td>1 (2,7%)</td><td>0,102</td></tr><tr><td>Patient décédés</td><td>15 (18 %)</td><td>3 (8,1%)</td><td>0,175</td></tr><tr><td>Délai médian entre greffe et<br>sortie du patient (jours) *</td><td>15 [12 - 21]</td><td>12 [9 - 16]</td><td>0,025</td></tr><tr><td>Taux de créatinine à la sortie<br>du patient (µmol/L) *</td><td>157 [113 - 211]</td><td>157 [117 - 198]</td><td>0,888</td></tr><tr><td>Taux de créatinine à 1 an<br>(µmol/L) (n=66) *</td><td>138 [111 - 161]</td><td>152 [125 - 194]</td><td>0,242</td></tr></tbody></table>

- Valeurs = nombre total

- * valeurs = Médianes [Q1-Q3]

<caption>Tableau 9. Analyses sur les greffons ayant repris leur fonction suite à la greffe</caption>

Analysis of the grafts that have regained their functions

## FC-203

### Right atrial strain, renal doppler and worsening renal function in acute decompensated pulmonary hypertension

PICHON Jérémie¹, ROCHE Anne¹, EBSTEIN Nathan¹, BOUCLY Athenais¹, CORTESE Jonathan¹, JEVNIKAR Mitja¹, JAIS Xavier¹, SITBON Olivier¹, MONTANI David¹, HUMBERT Marc¹, SAVALE Laurent¹
¹Hôpital Bicêtre APHP, Kremlin Bicêtre, France

**Correspondence:** Jérémie PICHON (jeremie.pichon1@gmail.com)

Annals of Intensive Care 2022, **12**(1):FC-203

**Rationale:** Although congestion has been identified as a main contributing element to the cardio-renal syndrome in acute right heart failure (RHF), right atrial (RA) mechanical performance has never been evaluated to predict worsening renal failure.

**Patients and methods/Materials and methods:** The aim of our study was to analyze the prognostic value of RA Strain in precapillary pulmonary hypertension (PH) patients admitted in intensive care unit (ICU) for acute RHF at admission and at day three. Congestion was assessed by alteration of the intrarenal Doppler, sushepatic and portal vein flow. The primary endpoint was the occurrence of acute kidney injury (AKI) KDIGO I-III.

**Results:** Among the 64 patients analyzed (66% female, age 60±16 years), all patients received intravenous diuretics and 36 (56%) required inotropic and/or vasopressor support. At ICU admission, the median values of peak, conduit, boost RA Strain and RA ejection fraction (EF) were respectively 12% [8-20], -5% [7-4], -7% [10-4] and 31% [20-41]. There is a good interobserver correlation (Rho = 0.94; p < 0.01). Peak RA strain higher than median value was significantly associated with higher eGFR (p = 0.02), lower renal resistive index (RRI; p = 0.01), lower renal venous stasis index (RVSI; p < 0.01) and lower volume excess ultrasound (VExUS; p < 0.01). A primary endpoint event occurred in 17 patients (26%). Event rate was higher in low RA EF (p = 0.02), in high RRI (p = 0.01) and high RVSI (p < 0.01) groups. At day 3, an increase in peak RA Strain and RA EF was both associated with fewer worsening of renal function. Patients with peak RA Strain > 20% at admission does not develop AKI during the stay.

**Conclusion:** RA Strain seems to be an easy-to-use bedside and relevant tool for evaluation of cardio-renal syndrome. It could help to predict worsening renal function in acute RHF.

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

## FC-204

### Permissive hypotension during sepsis: impact on fluid balance and renal prognosis

BLUM Laurene¹, LAVILLEGRAND Jean-Rémi¹, HARIRI Geoffroy¹, URBINA Tomas¹, BIGE Naike¹, BAUDEL Jean Luc¹, GUIDET Bertrand¹, MAURY Eric¹, AIT OUFELLA Hafid¹

¹APHP-CHU Saint Antoine, Paris, France

**Correspondence:** Jean-Rémi LAVILLEGRAND (jrlavillegrand@gmail.com)

Annals of Intensive Care 2022, **12**(1):FC-204

**Rationale:** The therapeutic management of sepsis includes control of the infectious source, fluid resuscitation associated with the introduction of catecholamines, primarily norepinephrine to maintain a mean arterial pressure (MAP > 65 mmHg). However, this MAP target remains debated, especially since MAP is not a direct reflection of tissue perfusion. Some authors suggest that MAP should be adapted individually to tissue perfusion. The objective of our work is to evaluate if a strategy called permissive hypotension, which consists in tolerating a moderate arterial hypotension when peripheral perfusion is preserved, has an impact on the fluid balance and on the renal function.

**Patients and methods/Materials and methods:** This was a single-center observational study. Patients with sepsis and MAP < 65 mmHg after 30 mL/kg fluid resuscitation were included. We compared 2 groups of patients, a so-called Septic Shock group that received
norepinephrine to maintain MAP > 65 mmHg and a Permissive Hypotension group in whom moderate hypotension was tolerated. The volume of fluids administered and the renal outcome (diuresis and change in creatinine) during the first days of management were studied.

**Results:** Over a period of 1 year, 94 patients were included, 79 in the septic shock group and 15 in the permissive hypotension group. Severity, assessed by SAPS 2 (60 [45–86] vs 45 [27–46], P = 0.0001) and SOFA score (7 [5–10] vs 4 [1–6], P < 0.0001), was greater in the Septic Shock group, as was organ support: invasive mechanical ventilation (71% vs 0%, P < 0.0001) and extra-renal replacement therapy (20% vs 0%, P = 0.06). In univariate analysis, mortality was lower in the Permissive Hypotension group (0% vs. 38%, P = 0.004) as was length of stay among survivors (3 [2–5] vs. 7 [4–14] days, P = 0.0004). The volume of fluid administration before admission to the ICU did not differ between the 2 groups (26 [20–32] vs 24 [18–33] mL/kg, p = 0.8. In contrast, during the first 6 h in the ICU, the volume administered was significantly lower in the Hypotensive Permissive group (500 [0–1000] versus 1000 [500–1500], p = 0.03). Renal function improved faster in the Permissive Hypotension group with a significantly lower KDIGO score at 48 h (0 [0–1] vs. 1 [0–2] (p < 0.05). Blood creatinine levels were not different at discharge between the 2 patient groups.

**Conclusion:** Permissive hypotension in sepsis, in the absence of clinical peripheral perfusion abnormalities, is very well tolerated. It is not accompanied by excess vascular filling or negative impact on renal function.

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

## FC-205

**Soluble TREM-1 plasma levels are associated with acute kidney injury, acute atrial fibrillation and prolonged ICU stay after cardiac surgery**

VANDESTIENNE Marie², BRAIK Rayan¹,², LAVILLEGRAND Jean-Rémi¹,², EL RIFAI Rida², HARIIRI Geoffroy¹, RAIA Lisa¹, DEMAILLY Zoe³, TARTOUR Eric¹,², BEN HAMOUDA Nadine¹,², TEDGUI Alain², BOUGLÉ Adrien¹, TAMION Fabienne³, CLAVIER Thomas³, AIT-OUFELLA Hafid²

¹APHP, Paris, France; ²PARCC INSERM, Paris, France; ³CHU Rouen, Rouen, France

**Correspondence:** Rayan BRAIK (rayan.braik@aphp.fr)

*Annals of Intensive Care* 2022, **12**(1):FC-205

**Rationale:** Cardiopulmonary bypass (CPB) during cardiac surgery leads to deleterious systemic inflammation. We hypothesized that TREM-1, a myeloid receptor, is engaged during CPB and shed in plasma.

**Patients and methods/Materials and methods:** During non-urgent cardiac surgery, we assessed 1/the kinetics of myeloid TREM-1 expression (flow cytometry), 2/the relationship between soluble (s)TREM-1 and pro-inflammatory cytokine plasma levels (ELISA) and 3/the association between sTREM-1 levels and postoperative outcome.

**Results:** In a first pilot study (N = 11), TREM-1 expression on neutrophils decreased between H0 and H2 while sTREM-1 plasma levels increased. In a second prospective cohort (N = 46), sTREM-1 levels increased at H2 and at H24 (p < 0.001). IL-6, IL-8, G-CSF and TNF-a, but not IL-1b, significantly increased at H2 compared to H0 (p < 0.001), but dropped at H24. Principal component analysis showed a close relationship between sTREM-1 and IL-8. Three patterns of patients were identified: Profile 1 with high baseline sTREM-1 levels and high increase and profile 2/3 with low/moderate baseline sTREM-1 levels and no/moderate increase overtime. Profile 1 patients developed more severe organ failure after CPB, with higher norepinephrine dose, higher SOFA score and more frequently acute kidney injury at both H24 and H48. Acute atrial fibrillation was also more frequent in profile 1 patients at H24 (80% vs 19.4%, p = 0.001). After adjustment on age and duration of CPB, sTREM-1 levels at H2 remained associated with ICU and hospital length of stay.

**Conclusion:** Early changes in sTREM-1 levels after cardiac surgery identified patients at high risk of post-operative complications and prolonged length of stay.

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

## FC-206

**Evaluation of balanced crystalloids on early renal recovery in patients with septic shock and continuous veno-venous hemofiltration: a retrospective observational study**

TETE Xavier¹, GRIFFIER Romain², PEARSON Marie-Fleur², TRAN VAN David¹
¹HIA Robert Picqué, Villenave D'ornon, France; ²CHU de Bordeaux, Bordeaux, France

**Correspondence:** Xavier TETE (xavier.tete@hotmail.fr)

*Annals of Intensive Care* 2022, **12**(1):FC-206

**Rationale:** The impact on renal function of balanced crystalloids versus normal saline has been extensively studied in recent randomised trials (1). However, few data are available regarding their impact on renal recovery, particularly in patients admitted to the ICU and receiving renal replacement therapy at admission. The objective of our study was to evaluate the impact of balanced crystalloids versus normal saline on renal recovery in patients admitted to the ICU for septic shock complicated by acute renal failure requiring continuous hemofiltration.

**Patients and methods/Materials and methods:** We conducted a single-center retrospective study including patients hospitalized in the intensive care unit between 2014 and 2019 who presented a septic shock with acute kidney injury requiring renal replacement therapy (RRT) within the first 48 h. The patients included were classified into two groups according to their exposure to balanced crystalloids. The primary endpoint was early renal recovery defined as definitive weaning from RRT by day 7.

**Results:** Of the 91 patients included in the study, 38 were classified in the balanced crystalloid (BCs) group and 53 in the unbalanced crystalloid (UBCs) group. The median volume of balanced crystalloids administered during the first 7 days was 0 ml (IQR [0;500]) in the UBCs group and 2000 ml (IQR [1312.5;2500]) in the BCs group (p < 0.001). The total volume of fluids administered was not statistically different between the BCs group and the UBCs group (p = 0.67). On day 7, 47.4% of patients in the BCs group recovered versus 58.5% in the UBCs group (p = 0.29). There was no difference after adjustment on confounding factors in multivariate analysis. The mean duration of RRT, maximum chloruremia, and ICU mortality were not significantly different between the two groups. In multivariate analysis, a positive fluid balance lower than 5% of baseline weight was associated with better renal recovery (OR 0.35; [0.13; 0.9]).

**Conclusion:** Our study did not find a benefit to the use of balanced crystalloids on renal recovery in our population of patients with septic shock complicated by AKI requiring early continuous hemofiltration. Further studies are needed to determine whether using balanced crystalloids improves renal recovery when renal replacement therapy is required.

**Reference 1:** Semler MW, Self WH, Wanderer JP, Ehrenfeld JM, Wang L, Byrne DW, et al. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med. mars 2018;378(9):829-39.

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

## FC-207

**Risk factors for mortality in anemic patients in the intensive care unit**

BENHAMZA Sabah¹, LAZRAQ Mohamed¹, ATAK Badreddine¹, BENSAID Abdelhak¹, MILOUDI Youssef¹, EL HARRAR Najib¹

¹Hôpital 20 Août 1953, CHUIR, Casablanca, Maroc

**Correspondence:** Sabah BENHAMZA (benhamzasabah5@gmail.com)

*Annals of Intensive Care* 2022, **12**(1):FC-207

**Rationale:** Anemia affects about two thirds of patients at admission to the ICU (1), and may lead to transfusions that may cause complications. Our objective was to specify the risk factors of mortality of anemic patients in our department.

**Patients and methods/Materials and methods:** Retrospective cohort over 1 year, in the intensive care unit of the 20 August hospital of Casablanca. All patients with anemia below 13 g/dl for men and 12 g/dl for women were included and excluded those coming from the hematology department or followed for a hematopathy.
**Results:** Out of 442 hospitalizations, 160 were included. The incidence of anemia was 36%. The mean age was 45 years, sex ratio M/F was 1.58. 26% were admitted for postoperative cephalic surgery and 12% for diabetic ketoacidosis. 82% of the patients were anemic at admission. Clinical signs were dominated by tachycardia (59%) and neurological disorders in (41%). Ferritinemia was collapsed in 39%, the infectious workup was positive with CRP and PCT elevated in 72% and 78% of cases respectively. 49% were transfused with red blood cells. 73% stayed less than 7 days and 15% more than 14 days. At discharge, 40% of the patients exceeded the threshold of 13 g/dL. 24% of our patients died. In multivariate analysis, the degree of anemia was not a risk factor for mortality, unlike SOFA score > 5 (OR 6.9 IC95% [2.7–17.4]) and blood transfusion which was a protective factor (OR = 0.3 IC 95% [0.2–0.7]).

**Conclusion:** The degree of anemia was not associated with mortality in our study, contrary to the SOFA score, because it is probably the comorbidities and the causal pathology that cause death.

**Reference 1:** 1- Zittoun J. Anémies macrocytaires carentielles. EMC 13–001-10 n.d.

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

FC-208

Thrombotic microangiopathy in ICU: a retrospective study of 20 years

KHARRAT Sana¹, TURKI Olfa¹, CHTARA Kamilia¹, BRADAI Sabrine¹, BAHLOUL Mabrouk¹, BOUAZIZ Mounir¹

¹CHU Habib bourguiba Sfax, Sfax, Tunisie

**Correspondence:** Olfa TURKI (olfa.turki.rea@gmail.com)

Annals of Intensive Care 2022, **12**(1):FC-208

**Rationale:** Thrombotic microangiopathy (TMA) is a rare condition. It covers a group of related disorders characterized by thrombosis in the micro-vascularization and by consequence organ dysfunction. It is responsible for significant morbidity and mortality. However, only a few reports have been published so far. The aim of the study was to describe our cohort of TMA in terms of incidence, clinical and-biological presentation, management and outcome. We also aimed to identify factors associated with poor prognosis.

**Patients and methods/Materials and methods:** Our study was retrospective, conducted in an intensive care unit. The study period was over 20 years: from January 1, 2001 to December 31, 2020. Our study included a descriptive part observing the different epidemiological, clinical, biological and characteristics of patients admitted for TMA and their evolution. The second part consisted on an analytical study highlighting the poor prognostic factors in our patients.

**Results:** A total of 37 patients were included. The incidence of TMA in the ICU was 0.18% with a female predominance and an average age of 34.8 years. Hemolytic anemia and thrombocytopenia were present in all patients. Neurological manifestations were the most frequent clinical signs (81.1%). Thrombotic thrombocytopenic purpura occupied ¾ of TMA's forms in our cohort. TMA was associated with pregnancy in 45.9% of cases. Medical support was based on plasma exchange (70.3%) in association with corticosteroids and immunoglobulins. Follow-up of the patient showed an exacerbation rate of 18.9% and complications such as infections in 45.9% of cases. Mortality rate was 29.7%. Factors correlated with poor prognosis in our cohort were age > 36 years, Glasgow score < 9 and platelet count < 14,000 elts/mm³ at admission.

**Conclusion:** TMA is still a cause of high mortality. A better knowledge of this disease and the awareness of physicians as well as the development of diagnostic methods could improve the prognosis.

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

FC-209

Impact of French lyophilized plasma transfusion in Trauma Center for severe civilian trauma patients

DELAMAIRE Flora¹, LEBOUVIER Thomas¹

¹CHU Rennes, Rennes, France

**Correspondence:** Flora DELAMAIRE (flora_d7@hotmail.com)

Annals of Intensive Care 2022, **12**(1):FC-209

**Rationale:** The initial management of severe trauma patients with hemorrhagic shock requires early blood products transfusion. Administration of high plasma: Red Blood Cell (RBC) ratio is associated with a reduction in mortality. French Lyophilized Plasma (FLYP) has been used for years for military prehospital care. We hypothesized that the use of FLYP for civilian severe trauma patients would reduce time for first plasma administration, reduce number of RBC transfused before first plasma and achieve a plasma:RBC transfusion ratio greater than 1:2.

**Patients and methods/Materials and methods:** This retrospective study was performed in a level 1 trauma center from January 2015 to June 2020. FLYP was available in trauma center since June 2017. Severe trauma patients who received massive transfusion (four RBC in the first hour and/or 10 RBC in the first 24 h) were included and divided in 2 groups according to the period of inclusion: Fresh Frozen Plasma (FFP) group before June 2017 and FLYP group after.

**Results:** Twenty-eight severe trauma patients were included in the FLYP group and 12 in the FFP group. The time until the first transfusion of plasma was shorter in the FLYP group, 35 min (IQR 20, 45) vs. 59 min (IQR 36.88) in the FFP group (p = 0.007). The number of RBC transfused before the first plasma was lower in the FLYP group than in the FFP group, respectively 2 vs. 3.67 (p = 0.002). The ratio plasma:RBC greater than 1:2 was obtained in 26 (93%) patients of the FLYP group vs 8 (67%) in the FFP group (p = 0.05).

**Conclusion:** FLYP permitted an early transfusion of plasma during the massive transfusion of severe trauma patients. It significantly reduced time for in hospital plasma delivery and improved the order of blood products transfusion. It could permit to obtain a greater than 1:2 plasma:RBC ratio in the trauma center. These results should be confirmed by a randomized trial.

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

<table><thead><tr><th></th><th>FFP group</th><th>FLYP group</th><th>P value</th></tr></thead><tbody><tr><td>Prehospital RBC, U, med</td><td>N=12<br>0,5</td><td>N=28<br>0,57</td><td>0,63</td></tr><tr><td>Prehospital RBC transfusion, n (%)</td><td>3/12 (25)</td><td>10/28 (36)</td><td>0,72</td></tr><tr><td>RBC in trauma center, U, med</td><td>4,75</td><td>3,89</td><td>0,37</td></tr><tr><td>RBC prehospital and in trauma center, U, med</td><td>5,25</td><td>4,46</td><td>0,5</td></tr><tr><td>RBC transfusion at 24h U, med</td><td>8,3</td><td>7,89</td><td>0,63</td></tr><tr><td>Ratio plasma:RBC in trauma center ≥ 1:2, n (%)</td><td>8/12 (67)</td><td>26/28 (93)</td><td>0,05</td></tr><tr><td>Plasma units (FFP+FLYP) in trauma center, U, med</td><td>3,25</td><td>2,68</td><td>0,797</td></tr><tr><td>Crystalloides volume received in trauma center, ml, med</td><td>1592</td><td>1536</td><td>0,917</td></tr><tr><td>RBC before first plasma, U, med</td><td>3,67</td><td>2</td><td>0,000227</td></tr><tr><td>Time to first unit of plasma, min, med (IQR)</td><td>59 (36-88)</td><td>35 (20-45)</td><td>0,0071</td></tr></tbody></table>

FFP: Fresh Frozen Plasma, FLYP: French Lyophilized Plasma, RBC: Red Blood Cells

Transfusion data: comparison of the FFP group and the FLYP group
## FC-210

### Storage time of transfused packed red blood cells and mortality in critically ill patients: a retrospective study

BEN DABEBISS Rafla¹, MAHMOUD Jihène¹, CHOUCHENE Salma¹, ZOUARI Hajer¹, BOUATAY Amina¹, HMOUDA Houssem¹

¹Sahloul University Hospital, Sousse, Tunisie

**Correspondence:** Rafla BEN DABEBISS (rafla_bendabebiss@hotmail.com)

Annals of Intensive Care 2022, **12**(1):FC-210

**Rationale:** Anemia is frequently diagnosed in intensive care. It may be present at admission or may develop during ICU stay due to blood loss secondary to frequent blood sampling in most of the cases. Red blood cell (RBC) transfusions may be lifesaving in some circumstances. However, several studies have reported increased morbidity and mortality in transfused patients due to "storage lesions" of older blood. This study focuses on outcome of transfused patients according to storage time of RBCs, and compares transfusion yield between older and newer blood.

**Patients and methods/Materials and methods:** This is a retrospective descriptive and analytical study of patients admitted between January 2014 and January 2021, who received RBC transfusion in the ICU. Epidemiological, clinical, and laboratory data were collected, as well as the number of transfused packed RBCs, storage time (age) of each unit, and estimation of blood spoliation secondary to blood sampling during ICU stay.

**Results:** During the study period, 80 patients were concerned by 150 transfusion episodes, including 236 packed RBCs. The mean age of patients was 57.1 ± 18.5 years. All patients had co-morbid conditions. Acute respiratory failure was the most frequent diagnosis present in 65% of cases at admission. The APACHE II score was 20.4 ± 9.4, and SAPS II score was 48.5 ± 21.1. The mean hemoglobin level at admission was 9 ± 2.7 g/dL. The mean pre-transfusion hemoglobin level was 6.9 ± 1.1 g/dL. The mean time to first ICU transfusion was 7.7 ± 8.7 days. Age of RBCs was 1 to 5 days in 21 transfusion episodes (14%), 6 to 10 days in 46 episodes (30.7%), 11 to 19 days in 59 episodes (39.3%), and ≥ 20 days in 24 transfusion episodes (16%). Mortality rate among transfused patients was 47.5%, and was related to severity of illness. Patients who received older blood did not have a significantly higher mortality (p=0.839), however the increment in hemoglobin per episode was significantly higher with newer blood (P=0.001). The mean value of blood spoliation was 426.7 ± 387.9 ml, and the number of transfusion episodes increased with blood spoliation and length of ICU stay. There was no statistically significant link between blood spoliation and mortality.

**Conclusion:** Newer transfused blood resulted in significantly higher hemoglobin increment. However, RBCs storage time did not affect mortality according to univariate and multivariate analysis.

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

## FC-211

### Survey on static physiologic parameters (single measure) that could guide red blood cell (RBC) transfusion practice in pediatric intensive care units (PICU), on behalf of the Pediatric Interest Group of the Canadian Critical Care Trials Group (CCCTG)

LACROIX Jacques¹, GALLAND Anne¹, TUCCI Marisa¹, LETEURTRE Stéphane², SARFATTI Avishay³, RAY Samiran⁴, STANWORTH Simon⁵, FONTELA Patricia⁶, KAWAGUCHI Atsushi⁷, DEMARET Pierre⁸, DUCRUET Thierry⁹, DU PONT-THIBODEAU Geneviève¹

¹CHU Sainte-Justine, Montreal, Canada; ²Réanimation et Surveillance Continue Pédiatriques, Hôpital Jeanne de Flandre, CHRU Lille, Lille, Lille, France; ³Paediatric Intensivist and research lead for paediatric critical care, Department of Pediatrics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK, Oxford, Royaume-Uni; ⁴Paediatric Intensivist, Department 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, Montreal, Canada

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

Annals of Intensive Care 2022, **12**(1):FC-211

**Rationale:** To determine what single value of physiological parameter threshold would guide the RBC transfusion practice of pediatric intensivists, in addition to hemoglobin (Hb) concentration.

**Patients and methods/Materials and methods:** Scenario-based self-administered questionnaire e-mailed to pediatric intensivists in 2021. Five scenarios were considered: 1) a previously healthy 4-year-old boy mechanically-ventilated after a severe multiple traumas, 2) idem, but with a toxic shock syndrome and ARDS, 3) idem, but after ablation of hepatoblastoma; 4) 5-month-old boy admitted to PICU following corrective surgery for tetralogy of Fallot; 5) 3-week-old boy with hypoplastic left heart syndrome admitted to PICU after Norwood + Sano procedure. Patients were hemodynamically stable in all scenarios. Respondents addressed three questions: 1. What baseline Hb concentration would prompt you to prescribe an RBC transfusion in this scenario? 2. Do you use the physiologic parameter to guide your RBC transfusion practice? What threshold of the parameters would prompt you to give an RBC transfusion if Hb is 1 g/dL above the baseline Hb that you chose in 1st question?

**Results:** 132 among 235 eligible respondents (56%) from France (50), United Kingdom (36), Canada (16), Japan (15) and Belgium (11) filled the questionnaire. The mean baseline Hb thresholds chosen are detailed in Table 1. Two out of 7 physiologic parameters (ScvO₂ and blood lactate) were used by more than 75% of respondents to guide their RBC transfusion practice (Table 1). The proportion of respondents who stated that they do not use some parameters was higher in the trauma case (range: 21% to 75%); it was lower for the other scenarios (range: 0% to 39%). The difference in use between the 5 scenarios was statistically significant for all parameters (P < 0.001). Table 1 also reports the threshold of 7 physiologic parameters used by respondents that would prompt them to prescribe an RBC transfusion if Hb is 1 g/dL above the baseline Hb concentration they chose. A ScvO₂ threshold of 58% emerged in four scenarios, but not for the post-operative cyanotic cardiac patient. Respondents agreed on a blood lactate threshold of 4 mmol/L in all scenarios.

**Conclusion:** The proportion of respondents who do not use some parameters changed with different basic disease. Only ScvO₂ and blood lactate were used by more than 75% of respondents to guide their RBC transfusion practice in PICU patients. Respondents seem to consider a ScvO₂ threshold of 58% and blood lactate threshold of 4 mmol/L.

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

<table><caption>Table 1. Physiologic parameters thresholds (single value, static marker) that would prompt respondents to prescribe an RBC transfusion if hemoglobin (Hb) is 1 g/dL above baseline Hb concentration</caption><thead><tr><th rowspan="3"></th><th rowspan="3">Respondents to scenario</th><th colspan="5">Scenario</th></tr><tr><th colspan="4">Question #1: baseline Hb concentration</th><th rowspan="2">P-value</th></tr><tr><th>Multiple trauma</th><th>Septic shock</th><th>Non cardiac surgery</th><th>Non cyanotic</th><th>Cyanotic</th></tr><tr><th></th><th></th><th>N= 106</th><th>N= 115</th><th>N= 98</th><th>N= 51</th><th>N= 50</th><th></th></tr><tr><th>Baseline Hb<sup>a</sup>/g/dL</th><th>Median (IQR)</th><td>7 (7-8)</td><td>8 (7-8)</td><td>7 (7-8)</td><td>9 (7-10)</td><td>10 (10-12)</td><td></td></tr><tr><th></th><th>Mean ± SD</th><td>6.7 ± 0.7</td><td>7.5 ± 1.2</td><td>6.7 ± 0.8</td><td>8.2 ± 1.5</td><td>10.4 ± 1.4</td><td></td></tr><tr><th>Physiologic parameter</th><th>Metrics</th><th colspan="5">Questions #2 and 3: respondents stating that they do not use the parameter or parameter threshold (median, IQR) that they chose to guide RBC transfusion practice</th><th></th></tr></thead><tbody><tr><td rowspan="2">PaO<sub>2</sub>/mmHg</td><td>Not used, %</td><td>61%</td><td>31%</td><td>13%</td><td>0%</td><td>80%</td><td>&lt;.001</td></tr><tr><td>Median (IQR)</td><td>65 (65-65)</td><td>65 (65-65)</td><td>65 (65-75)</td><td>65 (65-65)</td><td>70 (65-75)</td><td>0.99</td></tr><tr><td rowspan="2">SpO<sub>2</sub>, %</td><td>Not used, %</td><td>47%</td><td>16%</td><td>6%</td><td>0%</td><td>14%</td><td>&lt;.001</td></tr><tr><td>Median (IQR)</td><td>88 (83-88)</td><td>88 (83-88)</td><td>88 (83-88)</td><td>83 (83-88)</td><td>73 (73-73)</td><td>&lt;.001</td></tr><tr><td rowspan="2">PaO<sub>2</sub>/FiO<sub>2</sub> ratio</td><td>Not used, %</td><td>48%</td><td>31%</td><td>9%</td><td>7%</td><td>50%</td><td>&lt;.001</td></tr><tr><td>Median (IQR)</td><td>150 (125-175)</td><td>125 (75-175)</td><td>175 (75-175)</td><td>175 (175-225)</td><td>175 (75-225)</td><td>0.15</td></tr><tr><td rowspan="2">Oxygenation index †</td><td>Not used, %</td><td>64%</td><td>36%</td><td>3%</td><td>6%</td><td>31%</td><td>&lt;.001</td></tr><tr><td>Median (IQR)</td><td>23 (18-23)</td><td>23 (18-28)</td><td>23 (18-28)</td><td>23 (18-28)</td><td>23 (23-28)</td><td>0.35</td></tr><tr><td rowspan="2">SvO<sub>2</sub>, %</td><td>Not used, %</td><td>24%</td><td>10%</td><td>4%</td><td>0%</td><td>15%</td><td>&lt;.001</td></tr><tr><td>Median (IQR)</td><td>58 (53-63)</td><td>58 (53-63)</td><td>58 (48-63)</td><td>58 (48-58)</td><td>48 (48-58)</td><td>.002</td></tr><tr><td rowspan="2">Systemic O<sub>2</sub> extraction, %</td><td>Not used, %</td><td>76%</td><td>45%</td><td>5%</td><td>0%</td><td>0%</td><td>&lt;.001</td></tr><tr><td>Median (IQR)</td><td>43 (33-48)</td><td>43 (38-45)</td><td>43 (38-53)</td><td>43 (38-43)</td><td>38 (38-38)</td><td>.082</td></tr><tr><td rowspan="2">Blood lactate, mmol/L</td><td>Not used, %</td><td>21%</td><td>12%</td><td>2%</td><td>0%</td><td>0%</td><td>&lt;.001</td></tr><tr><td>Median (IQR)</td><td>4 (3-5)</td><td>4 (3-5)</td><td>4 (4-5)</td><td>4 (4-5)</td><td>4 (3-5)</td><td>0.94</td></tr></tbody></table>

<footnote>a Baseline Hb: Hb concentration chosen, given each scenario</footnote>

<footnote>b Oxygenation index, MAP = FiO₂ × 100 + PaO₂ in mmHg.</footnote>

<footnote>c ScvO₂: oxygenated blood; FiO₂: fraction of inspired O₂; IQR: interquartile range; RBC: red blood cell; SD: standard deviation; SpO₂: saturation measured by pulse oximetry.</footnote>

<footnote>d Hb: hemoglobin; FiO₂: fraction of inspired O₂; IQR: interquartile range; RBC: red blood cell; SD: standard deviation; SpO₂: saturation measured by pulse oximetry.</footnote>

<footnote>*Baseline Hb: Hb concentration chosen, given each scenario</footnote>
FC-212

Survey on how dynamic physiologic markers can modulate
the hemoglobin threshold and guide red blood cell (RBC)
transfusion practice in pediatric intensive care units (PICU),
on behalf of the CCCTG, PCCS, JICRG and GFRUP

GALLAND Anne<fnref n="1" />, TUCCI Marisa<fnref n="1" />, LETEUKTRE Stéphane<fnref n="2" />, SARFATTI
Avishay<fnref n="3" />, RAY Samiran<fnref n="4" />, STANWORTH Simon<fnref n="5" />, FONTELA Patricia⁶, KAWA
GUCHI Atsushi⁷, DEMARET Pierre⁸, DUCRUET Thierry⁹, LACROIX Jacques<fnref n="1" />,
DU PONT-THIBODEAU Geneviève<fnref n="1" />

¹Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, Canada; ²Rénaima- tion et Surveillance Continue Pédiatriques, Hôpital Jeanne de Flandre, CHRU Lille, Lille, France, 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, Université de Montréal, Montréal, Canada

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

Annals of Intensive Care 2022, 12(1):FC-212

**Rationale:** To determine if the trajectory (2 sequential measures) of dynamic physiologic parameters modulates the Hb threshold and guides the stated RBC transfusion practice of pediatric intensivists, in addition to hemoglobin (Hb) concentration.

**Patients and methods/Materials and methods:** Scenario-based self-administered questionnaire e-mailed to pediatric intensivists in 2021. There were five scenarios: 1) previously healthy 4-year-old boy mechanically-ventilated after a severe multiple trauma; 2) idem with toxic shock syndrome and ARDS; 3) idem after ablation of hepato-blastoma; 4) 5-month-old boy admitted to PICU following corrective surgery for tetralogy of Fallot; 5) 3-week-old boy with hypoplastic left heart syndrome admitted to PICU after a Norwood + Sano procedure. Respondents addressed two questions: 1. What Hb concentration would prompt you to prescribe an RBC transfusion to the patient in the scenario? 2. What would be the lowest acceptable Hb value that would prompt you to transfuse the patients described in the scenario given the Hb concentration that you chose (question #1) and the sequential results of the following physiologic parameters?

**Results:** 132 participants among 235 eligible respondents (56%) from France (50), United Kingdom (36), Canada (16), Japan (15) and Belgium (11) filled the questionnaire. Mean and median baseline Hb threshold are reported in Table 1. Two parameters (ScvO₂ and blood lactate) improved over time: the Hb threshold decrease was small in five scenarios for blood lactate and three scenarios for ScvO₂ (range: -0.2±0.1 to 0.1±0.9 g/dL), but it reached -0.4±1.1 and -0.6±0.7 g/dL for blood lactate in two cardiac scenarios. We did not find a statistically significant difference between scenarios for blood lactate (p=0.87), but the difference was significant when ScvO₂ increases from 50 to 70% (p<0.001). Four parameters worsened over time. Compared to mean baseline Hb threshold, the revised mean Hb threshold for transfusion decreased by ≤0.6 g/dL after worsening of PaO₂/FiO₂, DO₂, and VO₂ (p>0.05 between scenarios). However, the mean Hb threshold increased by ≥1 g/dL after ScvO₂ dropped from 70 to 50% (p<0.001 between scenarios).

**Conclusion:** Improvement of ScvO₂ or blood lactate did not prompt pediatric intensivists to decrease significantly their Hb threshold (<0.2 g/dL), unless the ScvO₂ increased from 50 to 70% after a cardiac surgery. A clinically significant drop in ScvO₂ (from 70 to 50%) caused a clinically significant increase in the revised Hb threshold in all scenarios (≥ 1.0 g/dL), but worsening PaO₂/FiO₂, DO₂ and VO₂ were associated with a lower Hb threshold (≤ -0.6 g/dL).

Compliance with ethics regulations: Yes in clinical research.

<table><caption>Table 1. Impact of the trajectory of dynamic physiologic parameters (two sequential results) on the mean and median difference (Δ) between the baseline and the revised hemoglobin threshold used by respondents to guide their red blood cell transfusion practice in PICU patients.</caption><thead><tr><th rowspan="2"></th><th rowspan="2">Respondents to scenario</th><th colspan="4">Scenario<fnref n="1" /></th><th colspan="2">Cardiac surgery</th><th rowspan="2">p-value</th></tr><tr><th>N=106</th><th>Multiple trauma</th><th>Septic shock</th><th>Non cardiac surgery</th><th>Non cyanotic</th><th>Cyanotic</th></tr></thead><tbody><tr><td colspan="9" style="text-align: left; font-weight: bold;">Question #1: baseline Hb concentration</td></tr><tr><td>Baseline Hb<sup>2</sup>, g/dL</td><td>Median (IQR)</td><td>7 (7-8)</td><td>8 (7-8)</td><td>7 (7-8)</td><td>8 (7-8)</td><td>9 (7-10)</td><td>10 (10-12)</td><td></td></tr><tr><td>Mean ± SD</td><td></td><td>6.7 ± 0.7</td><td>7.5 ± 1.2</td><td>6.7 ± 0.8</td><td>6.8 ± 0.8</td><td>8.2 ± 1.5</td><td>10.4 ± 1.4</td><td></td></tr><tr><td colspan="9" style="text-align: left; font-weight: bold;">Physiologic parameters</td></tr><tr><td></td><td>Metrics</td><td colspan="4">Difference (Δ) in threshold Hb level (g/dL) if the physiologic parameter improved over time</td><td colspan="2"></td><td></td></tr><tr><td>ScvO₂ increased from 50% to 70% in the last 4 hours</td><td>Respondents, N=14</td><td>76<sup>3</sup><br>Range: 5.5-9.5<br>-0.5</td><td>73<sup>3</sup><br>Range: 5.5-11.5<br>-1.5</td><td>62<sup>3</sup><br>Range: 5.5-9.5<br>-0.5</td><td>38<sup>3</sup><br>Range: 6.5-9.5<br>-1.5</td><td>34<sup>3</sup><br>Range: 7.5-11.5<br>-0.5</td><td></td><td></td></tr><tr><td>Lactate decreases from 6.2 to 3 mmol/L</td><td>Respondents, N=10</td><td>90<sup>3</sup><br>Range: 3-11<br>-0.2</td><td>99<sup>3</sup><br>Range: 3-12<br>-0.1</td><td>82<sup>3</sup><br>Range: 3-11<br>-0.1</td><td>-0.4<sup>3</sup><br>Range: 0-0.9<br>-0.1</td><td>-0.6<sup>3</sup><br>Range: 0-0.9<br>-0.1</td><td>&lt;0.01<sup>3</sup></td><td></td></tr><tr><td></td><td>Metric</td><td colspan="4">Difference (Δ) in threshold Hb level (g/dL) if the physiologic parameter worsened over time</td><td colspan="2"></td><td></td></tr><tr><td>PaO₂/O₂ drops from 200 to 100</td><td>Respondents, N=10</td><td>70<sup>3</sup><br>Range: 3-3<br>-0.6</td><td>72<sup>3</sup><br>Range: 3-1<br>-0.1</td><td>58<sup>3</sup><br>Range: 3-3<br>-0.5</td><td>26<sup>3</sup><br>Range: 3-1<br>-0.1</td><td>19<sup>3</sup><br>Range: 1-0<br>-0.1</td><td></td><td></td></tr><tr><td>DO₂ drops from 400 to 200 mL/min/m<fnref n="2" /></td><td>Respondents, N=14</td><td>34<sup>3</sup><br>Range: 3-2<br>-0.6</td><td>33<sup>3</sup><br>Range: 3-1<br>-0.1</td><td>28<sup>3</sup><br>Range: 3-1<br>-0.4</td><td>13<sup>3</sup><br>Range: 3-0<br>-0.5</td><td>14<sup>3</sup><br>Range: 0-0<br>-0.5</td><td></td><td></td></tr><tr><td>VO₂ drops from 120 to 90 mL/min/m<fnref n="2" /></td><td>Respondents, N=14</td><td>32<sup>3</sup><br>Range: 3-3<br>-0.1</td><td>27<sup>3</sup><br>Range: 3-0<br>-0.0</td><td>25<sup>3</sup><br>Range: 3-0<br>-0.0</td><td>12<sup>3</sup><br>Range: 0-0<br>-0.0</td><td>12<sup>3</sup><br>Range: 0-0<br>-0.0</td><td></td><td></td></tr><tr><td>ScvO₂ decreased from 70% to 50% in the last 4 hours</td><td>Respondents, N=86</td><td>6.5 ± 11.5<br>Range: 1.5<br>-1.6</td><td>6.5 ± 11.5<br>Range: 0.5<br>-1.1</td><td>6.5 ± 11.5<br>Range: 0.5<br>-1.3</td><td>6.5 ± 12.5<br>Range: 0.5<br>-1.3</td><td>7.5 ± 12.5<br>Range: 1.5<br>-1.3</td><td></td><td></td></tr><tr><td></td><td>Metric</td><td colspan="4">Difference (Δ) in threshold Hb level (g/dL) if the physiologic parameter improved over time</td><td colspan="2"></td><td></td></tr><tr><td>Baseline Hb: Hb concentration chosen, given each scenario</td><td></td><td colspan="4">1: Hb: revised hemoglobin (Hb) concentration; 2: Hb: revised difference between the median Hb revised to take into account a given trajectory of a dynamic physiologic parameter (for example two sequential ScvO₂ values) minus baseline Hb (top of the table) for the same scenario; 3: Hb: revised difference between the mean Hb revised to take into account a given trajectory of a dynamic physiologic parameter (for example two sequential ScvO₂ values) minus baseline Hb (top of the table) for the same scenario</td><td colspan="2"></td><td></td></tr></tbody></table>

Impact of the trajectory of dynamic physiologic parameters (2 sequential results) on mean and median difference between baseline and revised hemoglobin threshold used by respondents to guide their red blood cell transfusion practice in PICU patients.

FC-213

Thrombocytopenia and COVID-19: what prognostic value?

BOUCHECH Bouthaina<fnref n="1" />, BEN AMOR Oumaima<fnref n="2" />, CHTOUROU Ameni<fnref n="2" />, KOLSI Hichem<fnref n="2" />, KTATA Salma<fnref n="1" />, KESKES Mariem<fnref n="1" />, LOUATI Bilel<fnref n="2" />, KAROUI Abdelhamid<fnref n="1" />,<fnref n="2" />

¹hospital hbib bourguiba, Sfax, Tunisie; ²hospital de campagne Slim Chaker, Sfax, Tunisie

**Correspondence:** Bouthaina BOUCHECH (bouthainasellami@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-213

**Rationale:** Since December 2019, a severe acute respiratory syndrome coronavirus 2 is spreading rapidly around the world and became a pandemic. Among the confirmed cases, 15% developed severe forms and the mortality in intensive care units ranged from 30 to 70%. Indicators are needed to evaluate and predict the severity of the disease. We aimed to determine if thrombocytopenia is independently associated with poor outcomes in critically patients with COVID-19.

**Patients and methods/Materials and methods:** This was a retrospective study extended over a period from February to July 2021 including 240 infected patients by SARS-CoV-2. The exclusion criteria for this study were patients with progressive hematological pathology, patients with chronic renal failure and patients under anticoagulation or antiplatelet therapy before their infection with SARS-CoV-2. Biological monitoring of platelet levels was carried out in all patients admitted to intensive care on Day 1, Day 5, Day 12 and beyond 12 days every 72 h. All these patients had a preventive or curative anticoagulation by Low Molecular Weight Heparin. Thrombocytopenia was defined by platelet count <150 × 10⁹/L. For each patient, the nadir platelet count was identified and categorized into 3 groups: G1 [150–100]; G2 [100–50] and G3 [<50] (× 10⁹/L).

<footnote n="1">¹Baseline Hb: Hb concentration chosen, given each scenario.</footnote>

<footnote n="2">2 Δ median difference between the mean Hb concentration.</footnote>

<footnote n="3">3 Δ median difference between the median Hb revised to take into account a given trajectory of a dynamic physiologic parameter (for example two sequential ScvO₂ values) minus baseline Hb (top of the table) for the same scenario.</footnote>

<footnote n="4">4 Δ mean difference between the mean Hb revised to take into account a given trajectory of a dynamic physiologic parameter (for example two sequential ScvO₂ values) minus baseline Hb (top of the table) for the same scenario.</footnote>

<footnote n="5">5 Δ mean difference between the mean Hb revised to take into account a given trajectory of a dynamic physiologic parameter (for example two sequential ScvO₂ values) minus baseline Hb (top of the table) for the same scenario.</footnote>
**Results:** A total of 240 patients were included in this study, 60.7% of whom were male. The median age was 62.4 years. The diagnosis of the infection was made in 37% by a rapid test, 25.4% by RT-PCR and 82.6% by chest CT. 94% of patients received enoxaparin anticoagulation, 44.2% of whom had curative anticoagulation during their stay. We found that 26.7% had thrombocytopenia and for patients categorized into [150–100]; [100–50] and [< 50] groups, the thrombocytopenia was 5.1%, 12.3%, and 7.2% respectively. Patients developed thrombocytopenia between D1 and D27 with an average of 9.9 days (11%). Patients with thrombocytopenia died with significant difference (p = 0.3%). The G2 presented a statistically significant difference with (P = 0.07%) in terms of death as well as the early onset of thrombocytopenia (p = 0.065).

**Conclusion:** Although, it was a retrospective descriptive study and the tests on platelet count for each patient had different time intervals, this study confirms that thrombocytopenia upon admission is a strongly and independently associated with poor outcomes and mortality in patients hospitalized for SARS-CoV-2 pneumonia.

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

FC-214

Respiratory variations of Central Venous Pressure
during a standardized inspiration maneuver to predict
fluid responsiveness in spontaneously breathing patients:
a prospective, monocentric, diagnostic test evaluation

BOUREL Claire¹, DURAND Arthur¹, TERSCHIPHORST Benoit¹, ONIMUS
Thierry¹, FAVORY Raphael¹, PREAU Sebastien¹

¹CHU de Lille, Lille, France

**Correspondence:** Claire BOUREL (clairebourel@gmail.com)

Annals of Intensive Care 2022, **12**(1):FC-214

**Rationale:** Delayed or excessive volume expansion increases morbidity/mortality in acute circulatory failure patients. Therefore, prediction and assessment of fluid responsiveness (FR) is necessary. Hemodynamic parameters used to guide fluid therapy are regularly limited by spontaneous breathing (SB) or technicity. Central Venous Pressure (CVP) as a static parameter fails to accurately predict FR. The ideal marker to predict FR has to be accessible, fast, usable in spontaneous breathing and accurate. CVP respiratory variations (CVPv) could meet these criteria. We analyzed the accuracy of CVPv to predict FR in spontaneously breathing patients, and its optimization by a standardized inspiratory maneuver (SIM).

**Patients and methods/Materials and methods:** We carried out a monocentric, prospective, diagnostic test evaluation. Patients admitted to our intensive care units that were spontaneously breathing and had a central venous catheter were prospectively included. CVPv was measured while the patient was spontaneously breathing, with (CVPv-sim) and without SIM (CVPv-nsim), before and after a passive leg raising test (PLR). The SIM was validated by a buccal cavity pressure < -3 mmH₂O. CVPv accuracy to predict FR was evaluated. FR was defined as a PLR-induced increase in the velocity time integral of aortic blood flow during a passive leg raising maneuver (self-fluid challenge) ≥ 10%.

**Results:** Among 63 patients, 38 (60%) presented FR. CVPv-nsim was not significantly different between fluid responsive and fluid unresponsive patients (-4.9 mmHg [-7.5; -3.1] vs. -4.1 mmHg [-5.4; -2.8], respectively; p=0.15). CVPv-sim was higher in fluid responsive than fluid unresponsive patients (-3.6 mmHg [-10.6; -1.6] vs -9.7 mmHg [-13.9; -6.2], respectively; p<0.05). CVPv-sim < -4,5 mmHg predicted FR with a sensitivity of 89%, a specificity of 56%, and an area under ROC curve of 0.72 [0.56;0.86]. There were 4 false negative and 11 false positive patients. The overall median CVPv-sim increased from -8.6 mmHg [-12.5;-3.6] to -4.1 mmHg [-9.75; -0.25] during PLR (p<0.05). Among the 11 false positive results before PLR, 4 patients could not be analyzed during PLR, 4 patients moved from false positive to true negative and 3 increased their CVPv-sim but remained false positive during PLR.

**Conclusion:** In presence of a central venous catheter, CVPv may be useful to identify spontaneously breathing patients unresponsive to volume expansion.

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

FC-215

Prediction of fluid responsiveness by the corrected carotid flow
time changes during a passive leg rising maneuver

WATTECAMPS Guilhem¹, MORICONI Mickaël¹, TONNELIER Alexandre¹

¹CHIC Quimper, Quimper, France

**Correspondence:** Guilhem WATTECAMPS (guilhem.wattecamps.29@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-215

**Rationale:** The physician must rely on trustworthy and reliable tools to predict fluid responsiveness in order to provide an efficient and safe fluid expansion. We aimed to evaluate the ability of the measurement of corrected carotid flow time changes during a passive leg rising maneuver to predict fluid responsiveness among intensive care unit patients.

**Patients and methods/Materials and methods:** We performed a prospective and non-interventional study among patients in whom the physician in charge has decided a fluid expansion prior to the inclusion in the study. We performed the carotid flow time measurements before and after a passive leg rising maneuver. We used a linear Doppler probe. Fluid responsiveness was defined as an at least 15% rise in cardiac output following a fluid expansion of 500 mL of isotonic saline solution. Cardiac output was assessed after the PLR maneuver, thanks to a transpulmonay thermodilution PICCO₂® device. A second blinded investigator read the images recorded by the first one. We evaluated the accuracy of the cCFT changes through a ROC analysis. We evaluated the inter observers' agreement with a Bland Altman analysis.

**Results:** From January to July 2021, we included 21 patients, 13 responders and 8 non responders. The ROC analysis showed that a 4, 3% rise in cCFT predicted fluid responsiveness with a 76,9% sensitivity, a 87,5% specificity, a positive predictive value of 90,9% and a negative predictive value of 70%. The area under the curve was 0,85 CI 95% [0,68; 1]. In the post hoc blinded assessment, we showed a poor agreement between the two operators.

**Conclusion:** Correct Carotid Flow Time changes during a PLR maneuver may be a good tool to predict fluid responsiveness. However, the agreement between two observers is weak and could be an obstacle to its widespread use.

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

<figure><img src="image_99.png" /><figcaption>ROC curve of the corrected carotid flow time changes during a passive leg rising maneuver</figcaption></figure>
FC-216

**Acute circulatory failure: comparative study between a population with or without echocardiography in the emergency department of Oran university hospital**

ALACHAHER Djamel¹, GOULMANE Mourad¹, OUALI DADA Sofiane¹, SIDI AISSA Nabil¹, TABET AOUL Nabil¹

¹Centre hospitalo-universitaire d'Oran/Faculté de Médecine d'Oran.
Université Oran 1 Ahmed Ben Bella, Oran, Algeria

**Correspondence:** Djamel ALACHAHER (jalachaher@yahoo.fr)

*Annals of Intensive Care* 2022, **12**(1):FC-216

**Rationale:** Acute circulatory failures represent a frequent reason for hospitalization in the emergency department of the University hospital of Oran (CHUO), they are considered as serious states because in the absence of an adapted treatment, they can be rapidly life-threatening. The main objective of our study was to assess the contribution of echocardiography in our patients admitted in shock from a diagnostic, therapeutic and prognostic perspective.

**Patients and methods/Materials and methods:** A clinical and epidemiological, descriptive, prospective and mono-centric study was carried out in the medical emergency department of the CHU Oran concerning any patient aged over 15 years admitted for a non traumatic acute circulatory failure. The group of patients benefiting from trans-thoracic echocardiography (TTE) evaluated during a period of 2 years from 01-01-2016 to 31-12-2017 and designated the "echo yes" group was compared with a second group of patients who did not benefit from the TTE collected from 01-01-2015 to 31-12-2015 and named group "echo no".

**Results:** Seventy-seven (77) patients from the general population (n = 156) presenting a acute circulatory failure collected in our study benefited from TTE, i.e. a frequency of 49.35% with an average age of 64, 40 ± 17.70 years [17–106] and a sex ratio of 1.13, comorbidities were dominated by hypertension (59.70%) and diabetes (39%) and the reasons for consultation were represented by deterioration in general condition (74.30%) and disturbance of consciousness (50.64%). The ETT by two-dimensional exploration and Doppler allowed to determine the etiological mechanism in 94.8% of cases [38.96% (n = 30) hypovolemic shock, 36.36% (n = 28) cardiogenic shock, 88% (n = 13) septic shock and 2, 59% (n = 2) anaphylactic shock]. The rate of cases of undetermined mechanism decreased very significantly ("echo yes": 5.20% vs. "echo no": 36.70%), decrease by more than 31%, p < 0.001. The correction of the initial diagnostic hypothesis was noted in 29/77 patients, ie a frequency of 37.66%.

**Conclusion:** Our work has clearly illustrated and shown the contribution of TTE in improving the overall care of patients with shock by modifying the initial diagnostic hypothesis with, as corollary to the therapeutic management, to specify the etiological mechanism and to improve the prognosis of the patients.

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

FC-217

**Assessment of right ventricular mechanics by 3D transoesophageal echocardiography in the early phase of ARDS**

EVRARD Bruno¹, LAKATOS Bálint Károly², GOUDELIN Marine¹, VIGNON Philippe¹, KOVÁCS Attila²

¹CHU Limoges, Limoges, France; ²Heart and Cardiovascular Center, Semmelweis University, Budapest, Hongrie

**Correspondence:** Bruno EVRARD (bruno.evrard@chu-limoges.fr)

*Annals of Intensive Care* 2022, **12**(1):FC-217

**Rationale:** There are growing evidence distinguishing SARS-CoV-2-induced Acute Respiratory Distress Syndrome (ARDS) and those of other causes. This raises the possibility that severe COVID-19 may result in specific alterations of Right Ventricular (RV) mechanics. The objective was to compare global and axial right ventricular ejection fraction in ventilated patients for moderate-to-severe ARDS secondary to early SARS-CoV-2 pneumonia or to other causes, and in ventilated patients without ARDS used as reference.

**Patients and methods/Materials and methods:** Retrospective single-center cross-sectional study including 64 ventilated patients: 21

with ARDS related to SARS-CoV-2 (group 1), 22 with ARDS unrelated to SARS-CoV-2 (group 2), and 21 without ARDS (control group). Real-time three-dimensional transesophageal echocardiography was performed for hemodynamic assessment within 24 h after admission. Contraction pattern of the right ventricle was decomposed along the three anatomically relevant axes. Relative contribution of each spatial axis was evaluated by calculating ejection fraction along each axis divided by the global right ventricular ejection fraction.

**Results:** Global right ventricular ejection fraction was significantly lower in group 2 than in both group 1 and controls (median: 43% [25th–75th percentiles: 40–57] vs. 58% [55–62] and 65% [56–68], respectively: p < 0.001). Longitudinal shortening had a similar relative contribution to global right ventricular ejection fraction in all groups (group 1: 32% [28–39], group 2: 29% [24–40], control group: 31% [28–38], p = 0.6). Radial shortening was lower in group 2 when compared to both group 1 and controls (45% [40–53] vs. 57% [51–62] and 56% [50–60] respectively: p = 0.005). The relative contribution of right ventricular shortening along the anteroposterior axis was not statistically different between groups (group 1: 51% [41–55], group 2: 56% [46–63], control group; 56% [50–64], p = 0.076).

**Conclusion:** During early hemodynamic assessment, the right ventricular systolic function appears more impaired in ARDS unrelated to SARS-CoV-2 when compared to early stage SARS-CoV-2 ARDS. Radial shortening appears more involved than longitudinal and anteroposterior shortening in patients with ARDS unrelated to SARS-CoV-2 and decreased right ventricular ejection fraction.

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

FC-218

**Visualization of the superior vena cava using trans-thoracic echocardiography: learning curves using the cusum method**

SOLTANI Joséphine¹, PETIT Matthieu¹,², GODEMENT Mathieu¹, JULLIEN Edouard¹,², VIEILLARD-BARON Antoine¹,², CHARRON Cyril¹, GERI Guillaume¹

¹Hôpital Ambroise Paré, Boulogne Billancourt, France; ²Université Paris Saclay, Saclay, France

**Correspondence:** Guillaume GERI (dr.guillaume.geri@gmail.com)

*Annals of Intensive Care* 2022, **12**(1):FC-218

**Rationale:** Echocardiography is routinely used in the hemodynamic monitoring of ICU patients. Trans-esophageal echo (TEE) has been described to provide additional evaluation, especially on the superior vena cava (SVC). While trans-thoracic echo (TTE) remains a marginal tool in SVC evaluation, learning curve of such a skill is unknown.

**Patients and methods/Materials and methods:** Monocentric observational study performed in a tertiary medical ICU used to use TEE in hemodynamic monitoring. A theoretical training was provided to all the medical staff (i.e. the trainees) and a structured data collection was performed including history of echo training of each trainee as well as echo data (including 2-dimensional [2D] and time-movements [TM] screenshots). These screenshots were reviewed by an external blinded expert using a Likert-derived scale (0: incorrect, 1: not optimal and 2: correct) for 2D and TM views. The cumulative sum (CUSUM) method was used to evaluate the evolution of trainees' skills over time; an unacceptable failure rate (h1) and acceptable failure rate (h0) were a priori determined as 50 and 20%, respectively. Trainees who crossed h0 were considered successful while those crossing h1 had an unacceptable failure rate. Comparison of characteristics of trainees who succeeded and who failed were compared.

**Results:** 13 trainees were observed for a 2-months period. The median success rate was 77.8 [65.2, 80] and 33.3 [23.8, 42.9] for obtaining a correct 2D and a TM view, respectively. Three trainees crossed h0 for getting a correct 2D view while none did for a correct TM view. Crossing h0 occurred after 5, 12 and 17 procedures. Furthermore, all the trainees crossed h1 for the TM view, meaning the whole group crossed an unacceptable failure rate for this endpoint (Figure). The comparison of trainees who succeeded and who failed did not reveal any difference.

**Conclusion:** A one-shot theoretical training to get a correct visualization of the superior vena cava using TTE was not enough as most of them did not reach an acceptable failure rate.
**Compliance with ethics regulations:** Yes in clinical research.

<figure><img src="image_100.png" /><figcaption>CUSUM charts for 2D and TM views</figcaption></figure>

FC-219

**Cardiac manifestations in adult hemophagocytic
lymphohistiocytosis: clinical and echocardiographic study**

CERVEAUX Yohan¹, SLAMA Michel², MAIZEL Julien², BRAULT Clément²

¹Centre hospitalier ouest Réunion, Saint Paul, Reunion; ²Centre hospitalo-universitaire Amiens Picardie, Amiens, France

**Correspondence:** Yohan CERVEAUX (yohan.cerveaux@gmail.com)

Annals of Intensive Care 2022, **12**(1):FC-219

**Rationale:** Only a few cases of cardiac dysfunction in hemophagocytic lymphohistiocytosis (HLH) have been reported. However, the prognosis for these patients is poor. A complete echocardiographic evaluation may provide an important clue for a better understanding of the pathogenesis.

**Patients and methods/Materials and methods:** We conducted a retrospective study of all patients diagnosed with HLH and hospitalized in intensive care unit (ICU) between 2008 and 2020. All patients had to get a baseline echocardiography in the 2 years before ICU admission. We compared SALH cases versus patients with septic shock.

**Results:** We included 28 patients; all of them had haematological malignancies. Compared with baseline echocardiography, left ventricular ejection fraction (LVEF) was decreased during SALH (55% vs. 65%; p = 0.02), with no significant difference in cardiac output. Likewise, the right ventricle function, assessed by tricuspid annular plane systolic excursion (TAPSE), was significantly impaired (p < 0.01). Only 36% of SALH patients had a LVEF lower than 50% versus 63% of septic shock patients (p = 0.03).

**Conclusion:** Cardiac involvement in HLH patients is characterized by a left and right ventricular dysfunction, however, it is less frequent and severe than in septic cardiomyopathy. Cardiac involvement in HLH and in septic shock could share similar pathophysiological mechanisms or it might be the same clinical affection. A prospective study comparing septic myocarditis and HLH heart disease is needed to conclude.

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

FC-220

**How central venous oxygen saturation can be used
as a prognostic tool in cardiac surgery?**

KOLSI Hichem¹, JAWADI Wael¹, KESKES Mariem¹, SELLAMI Bouthaina¹,
KETATA Salma¹, AMOURI Salim¹, DERBEL Rahma¹, CHEIKHROUHOU
Hichem¹, TRIKI Zied¹

¹Centre hospitalo-universitaire Habib Bourguiba, Sfax, Sfax, Tunisie.

**Correspondence:** Hichem KOLSI (hichem.kolsi17@gmail.com)

Annals of Intensive Care 2022, **12**(1):FC-220

**Rationale:** Cardiac surgery with cardiopulmonary bypass (CPB) is known to be a lifesaving procedure. Nevertheless, CPB induces systemic inflammatory response and oxygenation impairment. Central venous oxygen saturation (ScvO₂) is a classic marker of dysoxia. Low and high ScvO₂ are associated with adverse outcome. However, there are no studies defining clearly abnormal values of ScvO₂ and assessing the prognostic interest of ScvO₂ in cardiac surgery. The aim of this study was to investigate the impact of increase and decrease of values of ScvO₂ on mortality and morbidity after cardiac surgery, and to define optimal thresholds of high and low ScvO₂ to predict complications.

**Patients and Methods/Materials and methods:** This was a prospective, observational, monocentric clinical study. We included 156 patients over 18 years undergoing cardiac surgery with CPB from September 2018 to January 2020. We have excluded patients who have died during surgery, patients who leave the operating room with a circulatory assistance technique and patients with misplacement of central venous catheter (CVC). Venous blood gas was collected from middle line of CVC. Population was divided into 2 groups: group H with ScvO₂ > 75% and group L with ScvO₂ ≤ 75%. In group H, we analyzed receiving operating curve (ROC) of ScvO₂ for occurring of postoperative complications. In group L, we analyzed ROC of—ScvO₂ for occurring of postoperative complications. We tested then the correlation of the variables with prognosis interest to ScvO₂ by Spearman test.

**Results:** Median age was 62 (53; 68). Complications rate was 37.8%. Mortality rate was 18.6%. In group H, we have found that ScvO₂ predicts complications with area under ROC 0.776. The best threshold was 80.6%. Moreover, we found that ScvO₂ is significantly correlated with CPB time, mechanical ventilation time and majority of postoperative prognosis scores. In group L, the area under ROC of—ScvO₂ concerning complications was 0.774. The best threshold was 69.7%. We found a significant negative correlation of ScvO₂ to CPB time, mechanical ventilation time and majority of postoperative prognosis scores.

**Conclusion:** We conclude that both low and high ScvO₂ are associated with adverse outcome after cardiac surgery. For patients with supranormal or low ScvO₂, we should use additional hemodynamic monitoring to facilitate adequate therapy in the postoperative course. Nevertheless, to place as a target for postoperative resuscitation algorithm, a randomized trial comparing a conventional resuscitation strategy with a strategy based on defined levels of ScvO₂ is essential.

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

FC-221

**Inappropriate intensive care unit stays: Perception
and experience of ICU caregivers**

MATHEY Lucas¹, JACQUIER Marine¹,², MEUNIER-BEILLARD Nicolas³,⁴,
ECARNOT Fiona⁵, ANDREU Pascal¹, ROUDAUT Jean-Baptiste¹, LABRUYERE
Marie¹,³, RIGAUD Jean-Philippe⁶,⁷, QUENOT Jean-Pierre¹,²,³,⁸

¹CHU Dijon, Dijon, France; ²Equipe Lipness, centre de recherche INSERM UMR1231 et LabEx LipSTIC, université de Bourgogne-Franche Comté, Dijon, France; ³INSERM, CIC 1432, Module Épidémiologie Clinique, université de Bourgogne-Franche Comté, Dijon, France; ⁴DRCI, USMR, CHU Dijon Bourgogne, Dijon, France; ⁵EA3920, Department of Cardiology, University Hospital Besançon, Besançon, France; ⁶Centre Hospitalier de Dieppe - Department of Intensive Care, Dieppe, France; ⁷Espace de Réflexion Éthique de Normandie, University Hospital Caen, Caen, France; ⁸Espace de Réflexion Éthique Bourgogne-Franche-Comté (EREBFC), Dijon, France
**Correspondence:** Jean-Pierre QUENOT (jean-pierre.quenot@chu-dijon.fr)

*Annals of Intensive Care* 2022, **12**(1):FC-221

**Rationale:** The question of futile or disproportionate care in the intensive care unit (ICU) has long been a subject of debate. It can happen that ICU stays come to be deemed inappropriate, after the fact, even by the ICU physicians themselves¹. This study aimed to describe and understand the perceptions of ICU caregivers about ICU stays that the ICU physicians themselves judge to be inappropriate.

**Patients and methods/Materials and methods:** We performed a qualitative study using semi-structured interviews with caregivers from 3 ICUs in the region of Burgundy-Franche-Comté. An interview guide was developed in advance and focused on 3 questions, namely: (1) what is your experience and perception of ICU stays that are judged after the fact to have been inappropriate? (2) What are the consequences of an inappropriate ICU stay, in your experience? (3) In your view, how could such stays be avoided? Interviews were recorded, transcribed in full and analyzed (in French) using thematic analysis. Participants were interviewed until saturation was reached.

**Results:** A total of 17 nurses and 4 nurses' aides were interviewed. Age, medical history, poor general status, deteriorating quality of life, and the lack of clear healthcare goals were the main criteria cited by respondents as possible reasons why an ICU stay would be deemed inappropriate after the fact by ICU physicians. The respondents also reported that certain specific circumstances may also give rise to ICU stays that could be inappropriate, e.g. emergency clinical situations, lack of knowledge about case, availability and/or choice of physicians, pressure from the patient's family or from other physicians to admit the patient, and refusal of death. Possible consequences of inappropriate ICU stays cited by our respondents included stress, anxiety, a feeling of incomprehension and inequality, deprivation of liberty, and loss of the feeling that their work is meaningful. Conversely, possible avenues to preventing inappropriate ICU stays cited by the respondents, included anticipation of acute care needs, and careful evaluation of the patient prior to admission.

**Conclusion:** In daily practice, paramedical caregivers understand how some ICU stays may come to be considered after the fact as having been inappropriate. They could undoubtedly provide valuable input into admission decisions, to avoid inappropriate ICU stays and to ensure equitable distribution of healthcare resources and the respect of patients' wishes.

**Reference 1:** Quenot JP, Large A, Meunier-Beillard N, et al. PlosOne 2019 Sep 6;14(9):e0222039.

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

## FC-222

### Non-beneficial admission to the Intensive Care Unit: A Nationwide Survey of Practices

QUENOT Jean-Pierre¹,²,³,⁴, JACQUIER Marine¹,³, FOURNEL Isabelle², MEUNIER-BEILLARD Nicolas²,⁵, GRANGÉ Clotilde¹, ECARNOT Fiona⁶, LABRUYERE Marie¹, RIGAUD Jean-Philippe⁷,⁸

¹CHU Dijon, Service de Médecine Intensive & Réanimation, Dijon, France; ²INSERM, CIC 1432, Module Epidémiologie Clinique, Dijon, France; ³CHU Dijon-Bourgogne, Centre d'Investigation Clinique, Module Epidémiologie Clinique/Essais Cliniques, Dijon, France; ⁴Equipe Lipness, centre de recherche INSERM UMR1231 et LabEx LipSTIC, université de Bourgogne-Franche Comté, Dijon, France; ⁵Espace de Réflexion Éthique Bourgogne-Franche-Comté (EREBFC), Dijon, France; ⁶DRCI, USMR, CHU Dijon Bourgogne, Dijon, France; ⁷Centre Hospitalier de Dieppe, Department of Intensive Care, Dieppe, France; ⁸Espace de Réflexion Éthique de Normandie, University Hospital Caen, Caen, France

**Correspondence:** Jean-Pierre QUENOT (jean-pierre.quenot@chu-dijon.fr)

*Annals of Intensive Care* 2022, **12**(1):FC-222

**Rationale:** Although the question of futile or disproportionate care in the intensive care unit (ICU) has been widely discussed in the literature, there is a paucity of studies about non-beneficial admissions to the ICU¹. Labelling ICU stays as non-beneficial may give a false perception of the utility of ICU management. Using a national survey of practices, we sought to define criteria for non-beneficial admissions to ICU, the circumstances in which they occur, and the possible consequences, with a view to identifying aspects that could be targeted for change.

**Patients and methods/Materials and methods:** An online survey was made available from 22 June to 4 October 2021 via the LimeSurvey platform for ICU physicians. For each question, the physician was asked to answer on a 5-point Likert scale (strongly disagree/disagree/neutral/agree/strongly agree). The survey used the Network for Research in Ethics in Critical Care to ensure representativeness of the participating ICUs and forms of practice of the respondents.

**Results:** In total, 154/164 ICU physicians contacted (94%) completed the online survey. The main results highlight that an ICU admission must take into account the expected survival and quality of life after discharge, in view of the current clinical status and prior medical history of the patient. The urgency of the clinical situation, a lack of knowledge of the medical file, and a failure to anticipate potential ICU requirement in the patient's healthcare trajectory are all factors that may lead to non-beneficial ICU admission. Stress, anxiety, incomprehension and even conflict with the patient's family or between healthcare providers are possible consequences of ICU admissions occurring in such circumstances. Finally, one of the key measures that could be implemented to reduce or avoid non-beneficial admissions is pluridisciplinary meetings prior to ICU, involving the patient, the family, referring and treating physicians, as well as an ICU physician when the possibility of ICU admission is part of the patient's healthcare goals.

**Conclusion:** This survey of practice suggests that there is a compelling need for shared reflection and decision-making, likely with greater involvement of ICU physicians, prior to ICU admission. This would take closer account of the preoccupations of non-ICU physicians, and could help to identify in advance the patients likely to benefit from ICU care, in coherence with their healthcare goals.

**Reference 1:** Quenot JP, Large A, Meunier-Beillard N, PlosOne 2019 Sep 6;14(9):e0222039.

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

## FC-223

### How is the COVID crisis a challenge for caregivers regarding the place of relatives in intensive care unit ?

DE VILLIERS DE LA NOUE Valentin¹,², VIALLARD Marcel-Louis¹

¹Université de Paris, Paris, France; ²CHU Robert Debré, Reims, France

**Correspondence:** Valentin DE VILLIERS DE LA NOUE (valentindelanoue@gmail.com)

*Annals of Intensive Care* 2022, **12**(1):FC-223

**Rationale:** Intensive care unit is a technical environment in which patients' lives are at stake. The COVID pandemic has led to a restriction of the place given to the entourage of patients hospitalized in the intensive care unit. How is the COVID crisis a challenge for caregivers in terms of the place of the family and friends in the ICU?

**Patients and methods/Materials and methods:** Qualitative study including 10 semi-directive interviews with caregivers working in the ICU.

**Results:** The COVID crisis disrupted the place of patients' relatives in ICU. This inclusion had been established by various means before the crisis: 24-h visits, participation to the mortuary toilet, pets' visits, log-book, family lounges, presence of volunteers. These means lead to a better inclusion of relatives in ICU, even if there were still difficulties in the relationship with the family and friends: management of the acute phase, difficulties in communicating with the family and friends,
waiting for care, choice of the person of trust, non-opening 24 h a day. The COVID crisis added barriers: initial closure of all the services in which the caregivers interviewed worked, then partial reopening, fear of the virus, constraints related to equipment, exacerbated communication difficulties, lack of medical time. The caregivers tried to implement new means to include relatives in this context: videoconferencing, virtual logbook, more regular telephone interviews. These difficulties in making room for the family and friends have deteriorated the relationship with the relatives, and the caregivers' experience regarding these changes is mostly negative.

**Conclusion:** COVID crisis was a challenge for caregivers to make room for the entourage of hospitalized patients. Despite the means implemented to maintain this link between caregivers and family members, the face-to-face relationship seems to be necessary for caregivers and family members to live serenely in the resuscitation context.

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

FC-224

**Withholding or withdrawing therapy in intensive care unit: an analysis of collaboration among intensivists and general practitioners**

ETCHEVERRY Jean-Baptiste¹, RAVRY Céline¹, GODARD Pierre¹,², MAYET Thierry¹, AUVET Adrien¹

¹CH de Dax, Dax, France; ²CHU Bordeaux, Bordeaux, France

**Correspondence:** Adrien AUVET (auveta@ch-dax.fr)

Annals of Intensive Care 2022, **12**(1):FC-224

**Rationale:** French law and practice guidelines (1) impose collegial procedures and interdisciplinary collaboration in end-of-life decision making. This procedure involves the intensive care unit (ICU) team and an external consultant. General practitioner (GP) could be a relevant consultant, through his understanding of the patient history and his relation with the family. The purpose of this study was to explore GP and intensivist point of views regarding the GP involvement in the collegial decision of withholding or withdrawing therapy.

**Patients and methods/Materials and methods:** We conducted a retrospective observational study over the year 2020. An online survey was sent by e-mail to the GPs and the intensivists of the 4 ICUs of a French mainland regional administrative county ("department").

**Results:** 132 GPs and 22 intensivists answered. Almost all of the GPs (118/132; 89%) had at least 1 patient in ICU over the year. (55/118; 47%) have been aware that end-of-life decision making concerned at least one of their patients. When such a process started, intensivists requested (26/55; 47%) of them to participate in the procedure. Intensivists requested an external consultant in 77% situations. Most of the time, they asked a specialist (91%) and rarely discussed with the GP (36%). 61% of GPs felt having a strong impact on the procedure, whereas 46% of intensivists considered GP impact this way. 71% of GPs felt involved by the ICU team in the collegial decision, whereas 37% of intensivists felt the same way about it. Those professionals acknowledge a similar GP influence regarding the patient management (38% GP, 40% intensivists). 85% of GPs would like to be more solicited, whereas 36% of intensivists gave a major place to GP interventions. 79% of GPs were requested by a family member to help them understand the situation.

**Conclusion:** Our study shows that intensivists involved the GPs partially in the collegial decision. This lack of participation seems to be in inadequacy with GPs wishes. A systematic involvement of the GP in the decision making of withholding or withdrawing treatment could be beneficial and could improve interaction with the family. Moreover, GP could be directly involved in the collegial decision making and not just as consultants.

**Reference 1:** 1- Société de réanimation de langue. Limitation et arrêt des traitements en réanimation adulte. Actualisation des recommandations de la Société de réanimation de langue française. Réanimation. déc 2010;19(8):679-98.

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

FC-225

**Anticipating need for intensive care unit admission in case of acute deterioration of chronic disease: a qualitative study among non-ICU physicians**

TAHA Alicia¹, JACQUIER Marine¹,², MEUNIER-BEILLARD Nicolas³,⁸, ECARNOT E⁴, ANDREU Pascal¹, ROUDAUT Jean-Baptiste¹, BRUYERE Marie¹,³, RIGAUD Jean-Philippe⁵,⁶, QUENOT Jean-Pierre¹,²,³,⁷

¹CHU Dijon, Dijon, France; ²Centre de recherche INSERM UMR1231 et LabEx LipSTIC, Université de Bourgogne-Franche Comté, Dijon, France; ³INSERM, CIC 1432, Module Épidémiologie Clinique, université de Bourgogne-Franche Comté, Dijon, France; ⁴EA3920, Department of Cardiology, University Hospital Besancon, Besancon, France; ⁵Department of Intensive Care, Centre Hospitalier de Dieppe, Dieppe, France; ⁶Espace de Réflexion Éthique de Normandie, University Hospital Caen, Caen, France; ⁷Espace de Réflexion Éthique Bourgogne Franche-Comté (EREBFC), Dijon, France; ⁸DRCI, USMR, CHU Dijon Bourgogne, Dijon, France

**Correspondence:** Jean-Pierre QUENOT (jean-pierre.quenot@chu-dijon.fr)

Annals of Intensive Care 2022, **12**(1):FC-225

**Rationale:** Almost 70% of patients who are admitted to the intensive care unit (ICU) suffer from at least one chronic disease (1). Chronic disease in ICU patients is an additional risk factor for death and is associated with significant post-ICU disability. This study aimed to explore reflections and perceptions of non-ICU physicians for the anticipation of need for ICU admission in case of acute decompensation in patients with chronic disease.

**Patients and methods/Materials and methods:** We performed a qualitative multicentre study using semi-structured interviews among non-ICU specialist physicians. The interview guide, developed in advance, focused on 3 questions: (1) What is your perception of ICU care? (2) How do you think advance directives can be integrated into the patient's healthcare goals? and (3) How can the possibility of a need for ICU admission be integrated into the patient's healthcare goals? Interviews were recorded, transcribed and analyzed by the-matic analysis. Interviews were performed until theoretical saturation was reached.

**Results:** In total, 16 physicians (8 women, 8 men) were interviewed. The main themes related to intensive care being viewed as a distinct specialty, dispensing very technical care, and with major human and ethical challenges, especially regarding end-of-life issues. The participants also mentioned the difficulty in anticipating an acute decompensation, and the choices that might have to be made in such a situation, for patient that they have known and followed for a long time. The timing of discussions for potential decompensation of the patient, the medical culture and the presence of advance directives are issues that arise when attempting to anticipate the question of ICU admission in the patient's healthcare goals or wishes. To facilitate this process, it was proposed that dedicated consultations bringing together the patient's referring physicians and ICU physicians could help to raise awareness and knowledge about ICU, and promote a palliative culture.

**Conclusion:** This study highlights the difficulties encountered by treating physicians of anticipating potential acute decompensation with ICU requirement in patients with chronic disease. It also opens perspectives for actions that could promote a pluridisciplinary
approach to anticipating acute decompensation and ICU require-
ments in patients with chronic disease.

**Reference 1:** Quenot JP, Helms J, Labro G, et al. Ann Intensive Care 2020;10:20.

Compliance with ethics regulations: Yes in clinical research.

FC-226

Anticipating need for intensive care unit admission in a patient's
healthcare trajectory: a qualitative study among general
practitioners

JACQUIER Marine¹,², FOUQUET Bérénice³, MEUNIER-BEILLARD Nicolas⁴,⁵
ECARNOT Fiona⁶, ANDREU Pascal¹, ROUDAUT Jean-Baptiste¹, LABRUYERE
Marie¹,⁴, RIGAUD Jean-Philippe⁷,⁸, QUENOT Jean-Pierre¹,²,⁴,⁹

¹CHU Dijon - Service de Médecine Intensive & Réanimation, Dijon, France; ²Equipe Lipness, centre de recherche INSERM UMR1231 et LabEx LipSTIC, université de Bourgogne-Franche Comté, Dijon, France; ³Ordre des médecins Rhône-Alpes, Lyon, France; ⁴INSERM, CIC 1432, Module Épidémiologie Clinique, université de Bourgogne-Franche Comté, Dijon, France; ⁵DRCI, USMR, CHU Dijon Bourgogne, Dijon, France; ⁶EA3920, Department of Cardiology, University Hospital Besançon, Besançon, France; ⁷Centre Hospitalier de Dieppe, Department of Intensive Care, Dieppe, France; ⁸Espace de Réflexion Éthique de Normandie, University Hospital Caen, Caen, France; ⁹Espace de Réflexion Éthique Bourgogne Franche-Comté (EREBFC), Dijon, France

Correspondence: Jean-Pierre QUENOT (jean-pierre.quenot@chu-dijon.fr)

Annals of Intensive Care 2022, 12(1):FC-226

**Rationale:** The questions raised by Intensive care unit (ICU) physicians with non-ICU physicians and particularly general practitioners (GPs) usually aim to anticipate possible acute decompensation and need for ICU admission in the patient. Intensivists also question their correspondents about the patient's wishes, with a view to avoiding unreasonable therapeutic obstinacy, or an ICU admission that might later be judged to have been inappropriate. We sought to explore GPs' perception and experience of ICU, and their manner of anticipating possible future ICU requirements for their patients.

**Patients and methods/Materials and methods:** We performed a qualitative study using semi-structured interviews with GPs practising in the Bourgogne and Pays-de-Loire regions of France. An interview guide was developed in advance, and focused on the following questions: (1) what is your perception of ICU? (2) what is your role in anticipating ICU requirements for your patients? (3) how do you feel about ICU stays that may later be judged to have been unjustified, or inappropriate. Interviews were recorded, transcribed and analysed by thematic analysis. Interviews were performed until theoretical saturation was reached.

**Results:** A total of 20 GPs were interviewed between February and August 2021. The main themes to emerge from the analysis were: (1) The GPs perceive ICU care as being that is very far removed from their ordinary daily practice. Their usually rare contacts with ICUs became more common during the COVID pandemic, strengthening relations between GPs and ICUs. (2) Improved knowledge of patients' wishes by GPs is desirable. This would make it possible, together with specialists during pluridisciplinary meetings, to better guide the patient's healthcare trajectory. (3) GPs are generally not familiar with the notion of unjustified or inappropriate ICU stays, and do not give it much thought. (4) Advance directives and end-of-life issues should be detailed in the patient's electronic medical record. However, due to a lack of time and training, GPs do not feel comfortable addressing these questions with their patients.

**Conclusion:** Anticipating ICU requirements in a patient's healthcare trajectory is difficult for GPs due to a lack of time, and a lack of training or education about ethical issues, which are not a major preoccupation in their daily practice. There is undoubtedly a compelling need to improve communication between hospital-based specialists, and

physicians working in primary care, and to incite the population to
think about preparing advance directives.

Compliance with ethics regulations: Yes in clinical research.

FC-227

Catastrophic COVID-19 delta variant surge in French West
Indies—report of an ICU triage policy

POMMIER Jean-David¹, DELAMARE Floran¹, MARTINO Frederic¹, VALETTE Marc¹, DEMOULE Alexandre², CAMOUS Laurent¹

¹CHU de guadeloupe, Les Abymes, Guadeloupe; ²CHU Pitié-Salpétrière, Paris, France

Correspondence: Laurent CAMOUS (laurent.camous@chu-guadeloupe.fr)

Annals of Intensive Care 2022, 12(1):FC-227

**Rationale:** Evaluate the results of crisis standards of care based on a multi-approach protocol in" real life conditions and the final outcome of all COVID-19 patients that have been proposed for admission to the intensive care unit (ICU) during a catastrophic delta variant SARS COV 2 surge overloading Intensive Care Unit (ICU) initial capacity.

**Patients and methods/Materials and methods:** All patients hospitalized in the University Hospital of Guadeloupe for COVID-19 pneumonia who were proposed for ICU admission during the surge peak from August 11th to September 10th were included. Retrospective analysis of population characteristics, outcome and death risk factors among patients admitted in ICU was performed.

**Results:** For this crisis, an ICU prioritization algorithm based on a multi-approach protocol was employed. According to day-by-day admission policy, three groups of patients were defined: "ICU ASAP", "ICU maybe" and "No ICU". During the 1-month study period, 328 patients were considered for ICU admission, of whom 132 (40%) were finally admitted. No "ICU ASAP" patients had to be refused of ICU admission due to Full ICU bed occupancy and 16 of the "ICU maybe" group patients had a secondary withdrawal of care". In the ICU admitted patients (n = 152), 80 patients were from the "ICU ASAP" group and 52 from the "ICU maybe" group. Hospital mortality was 24% in the "ICU ASAP" patients and 37% in the "ICU maybe" patients. Unsurprisingly, the "No ICU" group had a 77% mortality, reflecting severity of the patients. In ICU admitted patients, multivariate analysis found that late admission (> 48 H after first ICU referral) and hypertension were independent risk factor of death.

**Conclusion:** Multi approach protocol overcome a catastrophic COVID 19 Surge in Guadeloupe Island. Late admission (> 48 H after first referral) was grieved by raised ICU mortality in ICU eligible patients.

Compliance with ethics regulations: Yes in clinical research.

FC-228

Sepsis in the emergency departement: is procalcitonin predictive
of septic shock?

BAHRI Badra¹, KHIARI Saoussen¹, SEDGHIANI Ines¹, GHABARA Racha¹,
DOGHRI Hamdi¹, TOUJ Hajer¹, CHOUAIEB Sonia¹, BORSALI Nebiha¹

¹hospital habib thameur tunis, tunisie, Tunis, Tunisie

Correspondence: Saoussen KHIARI (saoussen.khiari@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-228

**Rationale:** Sepsis is frequent in the emergency department and a common cause of intensive care unit admission. Early recognition of patients at risk of septic shock is essential. The purpose of our study was to evaluate the prognostic value of procalcitonin (PCT) in patients admitted to the emergency department for sepsis.

**Patients and methods/Materials and methods:** Prospective monocentric observational study, conducted between July and December 2021. We included patients aged 18 and over, admitted to the emergency department for sepsis with a SOFA score greater than or equal to 2 and a suspected infection. The procalcitonin assay was performed on admission. The primary endpoint was the onset of septic shock.
The secondary endpoints were deaths in the emergency department, admission in intensive care and the use of mechanical ventilation.

**Results:** We included 137 patients aged on average $63.4 \pm 14$ years with a sex ratio of 1.49. The sites of infection sepsis were n (%): pulmonary 79 (58) including 60 (43) covid, urinary 38 (27), cutaneous 7 (5), digestive 8 (6), central nervous system 2 (1), and infective endocarditis 3 (2). The average PCT value was $9.16 \pm 24$ ng/ml and ranged from 0.03 to 100 ng/ml. The occurrence rate of a septic shock was 17.6% (n=24) requiring the use of norepinephrine. Overall mortality was 35% (n=48). The use of mechanical ventilation was indicated in 16.8% of cases. The intensive care admission rate was 20% (n=27). The average emergency room stay was $5 \pm 0.5$ days. The mean PCT in the shock group was 3.1 ng/ml versus 0.64 ng/ml in the non-shock group (p=0.006); the threshold value with the best sensitivity (79%) and specificity (43%) was 0.5 (Odds ratio=3.6; AUC=0.67). The mean PCT was 2.38 ng/ml in the deceased versus 0.43 ng/ml in the survivors (p=0.004). The PCT threshold value for predicting mortality with the best sensitivity (68%) and specificity (91%) was 0.7 ng/ml (odds ratio=2.1; AUC=0.64). We did not find significant difference in the use of mechanical ventilation (p=0.06).

**Conclusion:** Procalcitonin is a predictive factor for the onset of septic shock and mortality in patients admitted to the emergency department for sepsis.

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

FC-229

Histoplasmosis in the ICU: characteristics and outcome
a retrospective study (2014–2021) in the French west indies

CAMOUS Laurent¹, POMMIER Jean-David¹, SUREL Arthur¹, MARTINO Frederic¹, NICOLAS Muriel¹, CARLES Michel²

¹CHU de guadeloupe, Les Abymes, Guadeloupe; ²CHU de Nice, Nice, France

**Correspondence:** Laurent CAMOUS (laurent.camous@chu-guadeloupe.fr)

Annals of Intensive Care 2022, **12**(1):FC-229

**Rationale:** We aim to retrospectively identify the prevalence of severe histoplasmosis requiring intensive care management in a putative histoplasmosis endemic area without precise epidemiological data.

**Patients and methods/Materials and methods:** We conducted a retrospective review study of all adult patients (> 18 years old) who developed culture-confirmed histoplasmosis and admitted for a life-threatening event in the ICU of Guadeloupe University Hospital (GUH) from January 2014 to June 2021.

**Results:** 21 patients were included with a median age of 61 (50.0;67.0), mostly men (n=12, 57%). HIV was the most frequent underlying disease (n=8, 38%). All HIV patients, whether treated or not, were severely immunocompromised with a CD4 cell count below 50 per mm3. Other underlying conditions were ongoing immunosuppressive treatments (n=7, 33%), solid organ transplanted patients (N=3, 14%) and cancer patients (n=2, 10%)) (see Table 1). Three out of the 21 patients had no known immunosuppressive disorders but diabetes. The median IGS II at ICU admission was 63 (43.0;81.5). Median of symptoms duration before ICU admission was 23 days. The main clinical conditions requiring ICU admission were acute respiratory failure (n=15, 71%), and/or shock then coma (n=10 50%).

**Conclusion:** Histoplasmosis is a rare but life-threatening infection with pleomorphic organ involvement in immunocompromised host. Physicians must be aware of diagnosis tools to propose fast antifungal therapy.

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

FC-230

Severe community-acquired pneumonia due to Acinetobacter baumannii in Reunion Island: a retrospective observational study

ROTINI Giacomo¹, DEMANGOU Axel¹, BARON Marie¹, NATIVEL Mathilde¹, PUECH Bérénice¹, JABOT Julien¹, ALLOU Nicolas¹, VIDAL Charles¹
¹CHU Félix Gyuon, Saint Denis, Reunion

**Correspondence:** Charles VIDAL (charlesvidal@orange.fr)

Annals of Intensive Care 2022, **12**(1):FC-230

**Rationale:** *Acinetobacter baumannii (Ab)* is usually involved in nosocomial infection especially in intensive care units (ICU). Few studies report series of severe community-acquired pneumonia (CAP) due to this germ, particularly in tropical or sub-tropical regions. The objective of this work is to perform an epidemiological analysis of CAP caused by *Acinetobacter baumannii* (Ab) in Reunion Island.

**Patients and methods/Materials and methods:** It was a retrospective study including all patients hospitalized for CAP in ICUs at the Reunion University Hospital in the period 2014–2020. CAP to Ab was confirmed by microbiological respiratory samples or blood cultures realized at the admission in ICUs. All patients presented nosocomial infection or pneumonia to Ab were excluded.

**Results:** In the inclusion period, 572 patients were hospitalized in the ICUs for severe CAP, 6 of which were attributable to *Acinetobacter baumannii* (CAP-Ab). Patients with CAP-Ab had more alcohol disorders (67% vs 28%, OR=5, p=0.05) and denutrition state (50% vs 16%, OR=6.4, p=0.02) than patient with "standard CAP", 5/6 of patients with CAP-Ab were smokers. There was no statistically significant difference with diabetes, gender, immunosuppression and chronic respiratory diseases. Regarding the clinical presentation, patients with CAP-Ab presented septic shock (100%) and ARDS (67%). SOFA score at admission and mortality were higher (respectively 8 vs 3 and 83% vs 27% OR=13, p<0.01). All patients with CAP-Ab had initially received a first line inappropriate antibiotic therapy against Ab associating ceftriaxone/cefotaxime and spiramycine.

**Conclusion:** In Reunion Island, severe CAP due to *Acinetobacter baumannii* represent 1% of CAP hospitalized in ICU and are associated with high mortality. The severity of the initial clinical presentation as well as the presence of comorbidities such as alcohol disorders and denutrition should suggest this pathogen prompting a larger spectrum antibiotic therapy.

**Reference 1:** Leung, W.-S. et al. Fulminant Community-Acquired Acinetobacter baumannii Pneumonia as a Distinct Clinical Syndrome. Chest (2006).

**Reference 2:** Davis, J. S. et al. A 16-Year Prospective Study of Community-Onset Bacteremic Acinetobacter Pneumonia. Chest (2014).

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

FC-231

Safety of early discontinuation of an empiric combination
antibiotic regimen in severe community-acquired pneumonia:
the STOP study

GUILLOT Pauline¹, DELAMAIRE Flora¹, PAINVIN Benoit¹, PIAU Caroline¹, REIZINE Florian¹, LESOUHAITIER Mathieu¹, GACOUIN Arnaud¹, TADIE Jean-Marc¹, MAAMAR Adel¹

¹CHU de Rennes, Rennes, France

**Correspondence:** Pauline GUILLOT (pauline.guillot@chu-rennes.fr)

Annals of Intensive Care 2022, **12**(1):FC-231

**Rationale:** Severe community-acquired pneumonia (SCAP) is a leading cause of infectious mortality and a frequent reason for admission to
intensive care unit (ICU). The recommended empirical antibiotic treatment is an association of a β-lactam plus a macrolide or a respiratory fluoroquinolone. Treatment de-escalation strategies are not uniform. Our objective was to assess the safety of discontinuing atypical microorganism coverage in ICU.

**Patients and methods/Materials and methods:** We conducted a single-centre observational study over 6 years. Clinical data were collected retrospectively, microbiological data were collected prospectively. All consecutive patients over 18 years admitted to ICU with documented SCAP were included. All patients received an empirical combination therapy with a β-lactam plus a macrolide or quinolone. Legionella urine antigen test (UAT) was performed in all patients at admission. Macrolide or quinolone were discontinued if the UAT was negative. We examined the clinical and epidemiological characteristics of SCAP and analyzed the independent factors associated with ICU mortality.

**Results:** On 856 SCAP, 26 patients had atypical pneumonia: 18 Legionella pneumophila (LP) serogroup 1, 3 Mycoplasma pneumoniae (MP), and 5 Chlamydia psittaci (CP). There was no other Legionella serogroup or specie, and no Chlamydophila pneumoniae. UAT diagnosed 16 Legionella pneumonia. Combination therapy was discontinued for 5 patients with an atypical pneumonia: 1 with LP, 1 with MP and 2 with CP. Although the duration of mechanical ventilation was higher in atypical SCAP in univariate analysis, there was no significant difference in length of stay and ICU mortality compared with typical SCAP. The multivariate analysis showed SAPS II score (Odd-Ratio (OR)=1.04 by 1-point increment; 95% confidence interval (CI) 1.03–1.05, p<0.001) and the need for mechanical ventilation (OR=5.4; 95% CI 2.5–13.3, p<0.001) as independent factors associated with a higher ICU mortality. Type of microorganism was not associated with a higher ICU mortality.

**Conclusion:** In the absence of a specific history, it might be safe to discontinue macrolides or quinolones when Legionella UAT is negative. This "early" discontinuation strategy reduces antibiotic consumption, which has an economic and ecological impact on the human microbiota and antibiotic resistance. These results need to be confirmed in a multicentre study with a larger cohort.

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

Univariate and multivariate analyses between survivors and non-survivors

<table><thead><tr><th rowspan="2"></th><th colspan="2">Univariate analysis</th><th colspan="2">Multivariate analysis</th></tr><tr><th>Survivors<br>(n = 701)</th><th>Non-survivors<br>(n = 155)</th><th>p value</th><th>OR [95% CI]</th><th>p value</th></tr></thead><tbody><tr><td>Age</td><td>61 [50-70]</td><td>66 [57-74]</td><td>&lt; 0.001</td><td></td><td></td></tr><tr><td>Male gender</td><td>460 (67)</td><td>98 (63)</td><td>0.5</td><td></td><td></td></tr><tr><td>BMI</td><td>24 [21-29]</td><td>26 [23-31]</td><td>0.08</td><td></td><td></td></tr><tr><td>Natremia (mmol/L) at<br>admission</td><td>136 [133-140]</td><td>136 [133-139]</td><td>0.61</td><td></td><td></td></tr><tr><td>ASAT (U/L) at<br>admission</td><td>48 [29-95]</td><td>49 [31-102]</td><td>0.7</td><td></td><td></td></tr><tr><td>ALAT (U/L) at<br>admission</td><td>37 [22-66]</td><td>42 [26-67]</td><td>0.23</td><td></td><td></td></tr><tr><td>SAPS II score</td><td>36 [24-52]</td><td>63 [47-76]</td><td>&lt; 0.001</td><td>1.04 [1.03-1.05]</td><td>&lt; 0.001</td></tr><tr><td>Vasopressors &gt; 0.1<br>µg/kg/min at admission</td><td>377 (54)</td><td>84 (55)</td><td>1</td><td></td><td></td></tr><tr><td>Typical micro-organism</td><td>679 (97)</td><td>151 (97)</td><td>0.91</td><td></td><td></td></tr><tr><td>Mechanical ventilation</td><td>404 (58)</td><td>148 (96)</td><td>&lt; 0.001</td><td>5.4 [2.5-13.3]</td><td>&lt; 0.001</td></tr><tr><td>Duration of ventilation</td><td>4 [0-11]</td><td>6 [2-18]</td><td>&lt; 0.001</td><td></td><td></td></tr><tr><td>Length of stay in ICU</td><td>7 [3-14]</td><td>7 [3-19]</td><td>0.43</td><td></td><td></td></tr></tbody></table>

Data are presented as number (%) or median [interquartile range] in univariate analysis. Data are presented as odds ratios [confidence interval] in multivariate analysis.

List of abbreviations. ALAT, alanine aminotransferase; ASAT, aspartate aminotransferase; BMI, body mass index; ICU, intensive care unit; SAPS, simplified acute physiology score.

Univariate and multivariate analyses between survivors and non-survivors

FC-232

Clinical features and outcome of influenza pneumonia in critically-ill immunocompromised patients

RAYMOND Matthieu¹, MARTIN Maelle¹, LAMOUCHE-WILQUIN Pauline¹, BLONZ Gauthier¹, DESCAMPS Paul¹, AGBAKOU Maité¹, DESMEDT Luc¹, REIGNIER Jean¹, LASCARROU Jean Baptiste¹, CANET Emmanuel¹

¹CHU Nantes, Nantes, France

**Correspondence:** Matthieu RAYMOND (matthieu.raymond@chu-nantes.fr)

Annals of Intensive Care 2022, **12**(1):FC-232

**Rationale:** Immunocompromised patients are at risk of severe viral infections which may require ICU admission. Flu is responsible of yearly epidemic waves and influenza pneumonia may deteriorate into acute respiratory syndrome (ARDS). However, data on the outcome of influenza pneumonia in critically-ill immunocompromised patients are limited.

**Patients and methods/Materials and methods:** We conducted a single-center observational study. All patients admitted to the ICU of a French university-affiliated hospital for influenza pneumonia between December 1st 2016 and February 28th 2020 were included. The main objective was to compare the clinical features and outcome of critically-ill patients with flu according to their immunocompromised status.

**Results:** Overall, 137 patients (age 60 (± 2.77) years-old, 58.4% male) were included, of whom 58 (42.34%) were intubated. Forty-three (31.4%) patients were immunocompromised and 94 (68.6%) had no underlying immunosuppression. The main causes of immunosuppression were solid tumor (39.53%), hematological malignancies (37.21%) and solid-organ-transplantation (13.95%). ICU mortality was 13.97%, with mortality of immunocompromised patients being three-times that of patients without immunosuppression (25.58% versus 8.6%, p = 0.015). Immunocompromised patients were younger (58 vs 64 years-old, p = 0.02), had a higher Charlson comorbidity index (5.77 vs 3.12, p < 0.0001) and a worse Performance Status (1.72 vs 1.43, p = 0.02) compared to non-immunocompromised patients. In contrast, severity scores (SAPS II), hypoxemia (PaO₂/FiO₂ ratio), and ventilatory support at ICU admission were similar between the 2 groups. During the ICU stay, mechanical ventilation (MV) was implemented in 41.86% of immunocompromised patients and 42.55% of non-immunocompromised patients (p = 1). There was no difference in the rate of ventilator-associated pneumonia between the 2 groups (22.2 vs 22.5%, p = 1). Among MV patients, 10 (55.5%) immunocompromised patients developed severe ARDS compared to 13 (32.5%) non-immunocompromised patients (p = 0.02). On univariate analysis, factors associated with ICU mortality were older age, higher Charlson comorbidity index, worse Performance status, higher SAPS II, lower PaO₂/FiO₂ ratio, immunocompromised status, acute kidney injury, and the use of MV and vasopressors. On multivariable analysis, immunocompromised status was the only factor associated with increased ICU mortality (aOR 2.87 (1.07–7.69), p = 0.03).

**Conclusion:** Immunocompromised patients with severe influenza pneumonia were more likely to develop severe ARDS and had a three-fold increase in ICU mortality compared to non-immunocompromised patients. Such difference was not explained by an increased rate of ICU-acquired infections, suggesting that influenza virus was by itself responsible of a more severe form of pulmonary disease in immunocompromised patients. Further studies are needed to assess whether new antiviral drugs would translate into better patients' outcome.

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

FC-233

Relationship between prehospital modified Charlson Comorbidity Index and septic shock 30-day mortality

PARFAIT Pierre-Arnaud¹, JOUFFROY Romain¹,², GILBERT Basile³, TOURTIER Jean Pierre⁴, BLOCH-LAINE Emmanuel⁵, ECOLLAN Patrick⁶, BOULARAN Josiane⁷, BOUNES Vincent³, VIVIEN Benoit², GUEYE Papa⁸

¹APHP - CHRU Ambroise Paré, Boulogne-Billancourt, France; ²Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital - Assistance Publique - Hôpitaux Paris, Paris, France; ³Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France; ⁴Paris Fire Brigade, Paris, France; ⁵Emergency Department, Cochin Hospital, Paris, France & Emergency Department, SMUR, Hôtel Dieu Hospital - Assistance Publique - Hôpitaux Paris, Paris, France; ⁶Intensive Care Unit, SMUR, Pitie Salpêtrière Hospital - Assistance Publique - Hôpitaux Paris, Paris, France; ⁷SAMU 31, Castres Hospital, Castres, France; ⁸SAMU
972 University Hospital of Martinique, Fort-De-France Martinique, France

**Correspondence:** Romain JOUFFROY (romain.jouffroy@gmail.com)

*Annals of Intensive Care* 2022, **12**(1):FC-233

**Rationale:** In the prehospital setting, early identification of septic shock (SS) at risk of poor outcome is mainly based on clinical vital signs alteration evaluation. The Charlson Comorbidity Index (CCI) is an in-hospital tool used for burden of co-morbidity assessment. We report the relationship between the modified prehospital CCI, and 30-day mortality of SS patients initially cared for in the prehospital setting by a mobile ICU (MICU).

**Patients and methods/Materials and methods:** SS patients defined according to the 2012 sepsis-2 conference cared for by MICU between February 2017 and December 2021 were retrospectively analyzed. The modified prehospital CCI calculation was based on the available comorbid conditions collected in the prehospital setting. A threshold of ≥ 6, was chosen according to previous results.

**Results:** Five-hundred and twenty-nine patients with a mean age of 70 ± 15 years old were analyzed. Presumed origin of septic shock was mainly pulmonary (44%), digestive (25%) or urinary (16%). 30 day-mortality reached 31%. Propensity score analysis using a multivariate logistic regression of Inverse Probability Treatment Weighting, found a significant association between the 30-day mortality in the modified prehospital CCI ≥ 6: aOR = 1.11 [1.02–1.21], p < 10⁻³.

**Conclusion:** Among septic shock patients initially managed by a MICU in the prehospital setting, a significant association between 30-day mortality and the elevation of modified prehospital CCI of at least 6 is useful to early identify a poorer outcome.

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

FC-234

**Adequacy of probabilistic prehospital antibiotic therapy for septic shock**

HASSAN Anna¹, JOUFFROY Romain¹,², GILBERT Basile³, TOURTIER Jean

Pierre⁴, BLOCH-LAINE Emmanuel⁵, ECOLLAN Patrick⁶, BOULARAN

Josiane⁷, BOUNES Vincent³, VIVIEN Benoit², GUEYE Papa⁸

¹APHP - CHRU Ambroise Paré, Boulogne-Billancourt, France; ²Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital,

Assistance Publique - Hôpitaux de Paris, Université de Paris, Paris, France; ³Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France; ⁴Paris Fire Brigade, Paris, France; ⁵Emergency Department, Cochin Hospital, Paris, France & Emergency Department, SMUR, Hôtel Dieu Hospital - Assistance Publique - Hôpitaux de Paris, Paris, France; ⁶Intensive Care Unit, SMUR, Pitie Salpêtrière Hospital - Assistance Publique - Hôpitaux de Paris, Paris, France; ⁷SAMU 31, Castres Hospital, Castres, France; ⁸SAMU 972 University Hospital of Martinique, Fort-De-France Martinique, France

**Correspondence:** Romain JOUFFROY (romain.jouffroy@gmail.com)

*Annals of Intensive Care* 2022, **12**(1):FC-234

**Rationale:** Guidelines on sepsis management recommend early recognition, diagnosis and treatment, especially early antibiotic therapy (ABT) administration in order to reduce septic shock (SS) mortality. However, the adequacy of probabilistic prehospital ABT remains unknown.

**Patients and methods/Materials and methods:** From May 2016 to March 2021, all consecutive patients with SS managed by a prehospital mICU intervention were retrospectively analyzed.

**Results:** Among 386 patients retrospectively analyzed, 119 (33%) received probabilistic prehospital ABT, among which 74% received a 3rd generation cephalosporin: 31% cefotaxime and 42% ceftriaxone. No patient had a serious adverse effect related to ABT administration. Overall mortality rate on day-30 was 29%. Among the 119 patients with prehospital ABT, bacteriological identification was obtained for 81 (68%) patients with adequate prehospital ABT for 65 patients (80%) of which 10 (15%) deceased on day-30. Conversely, among the 16 (20%) patients with inadequate prehospital ABT, 9 patients (56%) deceased on day-30. Prehospital adequate ABT was significantly different between alive and deceased patients on day-30 (p = 4.10⁻³). After propensity score matching, a significant association between

adequate prehospital ABT administration and day-30 mortality was observed (aOR = 0.09 [0.01–0.47]). Inverse probability treatment weighting with multivariable logistic regression reported a day-30 mortality decrease in the adequate prehospital ABT group: aOR = 0.70 [0.53–0.93].

**Conclusion:** Among SS managed by a mICU, probabilistic prehospital ABT is most of the time adequate and associated with a day-30 mortality decrease. Further prospective studies are needed to confirm these results and the weight of prehospital ABT in the prehospital bundle of care for SS.

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

<figure><img src="image_101.png" /></figure>

Study flow chart

FC-235

**Usefulness of Procalcitonin for cervicofacial cellulitis prognosis in intensive care**

BENHAMZA Sabah¹,², LAZRAQ Mohamed¹,², MILOUDI Youssef¹,², BENSAID Abdelhak¹,², EL HARRAR Najib¹,²

¹Hôpital 20 Août 1953, CHUIR, Casablanca, Maroc; ²Université Hassan II, faculté de médecine et de pharmacie, Casablanca, Maroc

**Correspondence:** Sabah BENHAMZA (benhamzasabah5@gmail.com)

*Annals of Intensive Care* 2022, **12**(1):FC-235

**Rationale:** Cervicofacial cellulitis (CFC) is a severe infection of the subcutaneous cellular tissue, and is one of the most serious head and neck infectious emergencies [1]. Procalcitonin (PCT) is a "specific marker of bacterial infection" [2]. Our objective was to evaluate the prognostic value of PCT in CFC in intensive care unit.

**Patients and methods/Materials and methods:** retrospective cohort over 6 years which covered all patients treated for CFC in intensive care unit at the August 20 hospital in Casablanca. All patients with less than two PCT assays were excluded.

**Results:** 47 patients were admitted for CFC during the duration of our study, 30 of whom had at least 2 PCT values. The annual incidence of CFC was 8 cases/year. The average age was 41 years old. The sex ratio was 1. The main medical history of admitted patients was diabetes (33.33%), hypertension (22.33%) and poor oral health (22.33%). The infectious gateway was dental in 53.33%. The average consultation time was 12 days. The main complications were upper aerodigestive tract obstruction (43.33%), mediastinitis (40%) and meningeal extension (13.3%). Positive PCT was found in 60% of cases. In bivariate analysis, positive PCT at admission was associated with mortality (p = 0.04), but not with length of stay (p = 0.49) or septic shock (p = 0.52) neither other clinical or biological parameters. The ascending kinetics of PCT was associated with the duration of hospitalization (0.017) but not with death.

**Conclusion:** Elevated PCT at admission seems to have prognostic rather than diagnostic value, multicenter studies should confirm this result.

**Reference 1:** 1) Bennani-Baïti, A A et al. "Cervicofacial cellulitis: The impact of non-steroidal anti-inflammatory drugs. A study of 70 cases." European annals of otorhinolaryngology, head and neck diseases vol. 132,4 (2015): 181–4. https://doi.org/10.1016/j.anorl.2015.06.004
**Reference 2:** 2) Venet, C., et al. "Marqueurs biologiques de l'infection en réanimation chez l'adulte?: place de la procalcitonine Biological markers of infection in critically ill adult patients: role of procalcitonin." Réanimation, vol. 11, no. 3, May 2002, pp. 156-

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

FC-236

**Characterization of endotracheal tube biofilm in critically ill patients, lessons from a novel microbiological compartment**

MALDINEY Thomas<fnref n="1" />, PINEAU Valentin², NEUWIRTH Catherine², OUZEN Linda², EBERL Isabelle², JEUDY Géraldine², DALAC Sophie², PIROTH Lionel², BLOT Mathieu², SAUTOUR Marc², DALLE Frédéric², ABDULMALAK Caroline<fnref n="1" />, TER SCHIPHORST Romain<fnref n="1" />, PUGLIESI Paul-Simon<fnref n="1" />, POUSSANT Thomas<fnref n="1" />, OGIER-DESSERREY Agathe<fnref n="1" />, FOURNEL Isabelle², DE GIRAUD D'AGAY Melchior², JACQUIER Marine², LABRUYÈRE Marie², APTEL François², ROUDAUT Jean-Baptiste², VIEILLE Thibault², ANDREU Pascal², PRIN Sébastien², CHARLES Pierre-Emmanuel², HAMET Maël<fnref n="1" />, QUENOT Jean-Pierre²

**Correspondence:** Thomas MALDINEY (thomas.maldiney@gmx.com)

*Annals of Intensive Care* 2022, **12**(1):FC-236

**Rationale:** Biofilm (BF) is considered to have a major impact on the development of ventilator-associated pneumonia (VAP) in intensive care unit (ICU) [1]. Despite an increasing amount of relevant data regarding the formation of BF [2], significant results are still lacking to understand the potential implication of endotracheal tube (ETT)-BF dispersal and better characterize the impact of its mesostructure and microbiological singularity on the occurrence of VAP.

**Patients and methods/Materials and methods:** We conducted a multicenter retrospective observational study in both William Morey general hospital and the University Hospital of Dijon between March and May 2021. Patients admitted in the ICU who required for more than 48 h invasive mechanical ventilation (MV) were screened for subsequent ETT characterization. Following tracheal extubation, we collected ETT, studied the mesostructural morphology of ETT-deposited BF with confocal microscopy (CM) and compared its microbiological characteristics to other colonization/infection sites.

**Results:** A total of 64 ETT were included in the study. Confocal microscopy acquisitions of ETT sections revealed a significant correlation between BF thickness and MV duration as well as two main morphological aspects of ETT-deposited BF (Fig. 1A to 1D): a thinner continuous ribbon-shaped (rs) aspect, less likely mono-bacterial and predominantly associated with Enterobacter spp., *Streptococcus pneumoniae* or Viridans streptococci, and a thicker discontinuous mushroom-shaped (ms) appearance more likely correlated with the association of bacterial and fungal species in respiratory samples (Fig. 1E). The microbiological characterization of ETT-deposited BF and subsequent cartography allowed the identification of additional species only in BF (Fig. 1F and 1G) with higher acquired resistance in more than 80% of analyzed BF phenotypes when compared to other colonization sites from the patient's environment.

**Conclusion:** The present study reveals novel morphological and microbiological data regarding ETT-deposited BF characterization and formation in ICU patients. BF sampling as well as microbiological phenotypic cartography returned precious information regarding the acquisition of BF-exclusive species with preeminent antibiotic resistance and would therefore constitute a clinical value added in the perspective of future ETT-deposited BF-based antimicrobial stewardship in critically ill patients at increased risk for VAP.

**Reference 1:** Fernández-Barat L, Torres A. Biofilms in ventilator-associated pneumonia. Future Microbiology. déc 2016;11(12):1599-610.

**Reference 2:** Thorarinsdottir HR, Kander T, Holmberg A, Petronis S, Klarin B. Biofilm formation on three different endotracheal tubes: a prospective clinical trial. Crit Care. déc 2020;24(1):382.

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

<figure><img src="image_102.png" /></figure>

ETT-deposited BF characterization. A) ETT section. B) CM of rs BF (bar, 50 µm). C) CM of ms BF (bar, 25 µm). D) MV duration-BF thickness correlation. E) BF bacterial-fungal distribution. F-G) BF lost-found differential species/patient (F) or median (G).

FC-237

**Inhaled bacteriophage therapy in a porcine model of pneumonia caused by Pseudomonas aeruginosa during mechanical ventilation**

GUILLON Antoine<fnref n="1" />,², PARDESSUS Jeoffrey², L'HOSTIS Guillaume³, FEVRE Cindy ³, BARC Céline⁴, DALLONEAU Emilie², JOUAN Youenn<fnref n="1" />,², BODIER Elsa<fnref n="1" />,², PEREZ Yonatan<fnref n="1" />,², THOREY Camille<fnref n="1" />,², MEREGHETTI Laurent <fnref n="1" />, CABRERA Maria², RIOU Mickael⁴, VECELLIO Laurent², LEGUELLEC Sandrine⁵, VOURC'H Nathalie ².

**Correspondence:** Antoine GUILLON (antoine.guillon@univ-tours.fr)

*Annals of Intensive Care* 2022, **12**(1):FC-237

**Rationale:** *Pseudomonas aeruginosa* is a main cause of ventilator-associated pneumonia (VAP) with drug-resistant bacteria. Bacteriophage therapy has experienced resurgence to compensate for the limited development of novel antibiotics. However, phage therapy is limited to a compassionate use so far, resulting from lack of adequate studies in relevant pharmacological models. We used a pig model of pneumonia caused by *P. aeruginosa* that recapitulates essential features of human disease to study the antimicrobial efficacy of nebulized-phage therapy.

**Patients and methods/Materials and methods:** (i) Lysis kinetic assays were performed to evaluate in vitro phage antibacterial efficacy against *P. aeruginosa* and select relevant combinations of lytic phages. (ii) The efficacy of the phage combinations was investigated in vivo (murine model of *P. aeruginosa* lung infection). (iii) We determined the optimal conditions to ensure efficient phage delivery by aerosol during mechanical ventilation. (iv) Lung antimicrobial efficacy

<footnote n="1">¹William Morey Hospital, Chalon-Sur-Saône, France; ²Dijon University Hospital, Dijon, France</footnote>

<footnote n="1">¹CHRU Tours, Tours, France; ²INSERM, Centre d'Etude des Pathologies Respiratoires, U1100, Tours, France; ³Pherecydes Pharma, Research and Development, Romainville, France; ⁴INRAE, UE-1277 Plateforme d'infectiologie expérimentale (PFIE), Nouzilly, France; ⁵DTF-Aerodrug, Faculté de Médecine, Tours, France</footnote>
of inhaled-phage therapy was evaluated in pigs, which were anaesthe-
tized, mechanically ventilated and infected with *P. aeruginosa*.

**Results:** By selecting an active phage cocktail and optimizing aerosol delivery conditions, we were able to deliver high phage concentrations in the lungs, which resulted in a rapid and marked reduction in *P. aeruginosa* density (1.5-log reduction, p < 0.001). No infective phage was detected in the sera and urines throughout the experiment.

**Conclusion:** Our findings demonstrated (i) the feasibility of delivering large amounts of active phages by nebulization during mechanical ventilation and (ii) rapid control of in situ infection by inhaled bacteriophage in an experimental model of *P. aeruginosa* pneumonia with high translational value.

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

FC-238

Risk factors for a first episode of ventilator-associated pneumonia
caused by Stenotrophomonas Maltophilia

CANIVET Clemence¹, TEYSSEYRE Laura¹, AUJOULAT Thomas¹, CARON
Margot¹, NATIVEL Mathilde¹, MILTGEN Guillaume¹, VIDAL Charles¹, ALLOU
Nicolas¹, PUECH Berenice¹

¹CHU Felix Guyon, Saint Denis, Reunion

**Correspondence:** Bérénice PUECH (berenice.puech@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-238

**Rationale:** The incidence of ventilator-associated pneumonia caused by Stenotrophomonas maltophilia (SM-VAP) is on the rise. This disease is associated with increased morbidity and mortality in intensive care unit (ICU), notably due to intrinsic resistance and ineffective probabilistic antibiotic therapy. Our study aimed to determine the risk factors for a first episode of SM-VAP in ICU.

**Patients and methods/Materials and methods:** This single center retrospective study was conducted from 2010 to 2018 in the polyvalent ICU of University Hospital. All patients who developed ventilator-associated pneumonia (VAP) during their ICU stay were consecutively evaluated. Patients with a first episode of SM-VAP were compared to those with a first episode of VAP caused by another microorganism.

**Results:** A total of 89 patients developed a first episode of SM-VAP over the study period. In the group of patients with SM-VAP, infection was polymicrobial in 43.8% of cases and ICU mortality was 49.4%. After multivariate logistic regression analysis, the risk factors for a first episode of SM-VAP were: chronic respiratory failure (Odds Ratio (OR): 4.212; 95% Confidence Interval (CI): 1.776-9.989; p = 0.001), chronic renal failure (OR: 2.693; 95% CI: 1.356-5.352; p = 0.05), use of third-generation cephalosporins active against *Pseudomonas aeruginosa* (OR 2.862; 95% CI: 1.505-5.442; p = 0.001), and female sex (OR: 2.646; 95% CI: 1.458-.808; p = 0.001).

**Conclusion:** In our study, chronic respiratory failure, chronic renal failure, use of third-generation cephalosporins active against *P. aerugi-
nosa*, and female sex were identified as risk factors for a first episode
of SM-VAP.

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

FC-239

Ventilator associated pneumonia among severe Covid-19 related ARDS patients

ZGHIDI Marwa¹, BEN SAIDA Imen¹,², MAATOUK Iyed¹, HAMDI Dhouha¹,
BOUBTANE Rhab¹, BOUSSARSAR Mohamed¹

¹Farhat Hached University Hospital, Medical Intensive Care Unit, Sousse, TUNISIA, Sousse, Tunisia; ²Research Laboratory N° LR12SP09. Heart Failure. Farhat Hached University Hospital, Sousse, Tunisia, Sousse, Tunisia, Tunisie

**Correspondence:** Marwa ZGHIDI (marwa_zghidi@outlook.fr)

Annals of Intensive Care 2022, 12(1):FC-239

**Rationale:** The pandemic of coronavirus disease 2019 (covid19) has resulted in high rates of hospitalization in intensive care units (ICU) with widespread use of invasive mechanical ventilation (IMV) which exposes patients to the risk of ventilator-associated pneumonia (VAP). The objectives were: to determine the trends in frequencies and to analyze the characteristics, prognosis and risk factors of ventilator-associated pneumonia, in severe Covid-19 related ARDS patients.

**Patients and methods/Materials and methods:** This was a retrospective study of patients hospitalized with severe COVID-19 from March 2020 to October 2021, in a medical intensive care unit who required mechanical ventilation for more than 48 h. The study period was divided in three transition stages corresponding to each new adjustment. VAP was identified by using a combination of clinical, imaging and laboratory criteria. Univariate analysis and multivariable logistic regression were used to analyze the associated factors with VAP.

**Results:** During the study period, 442 patients with positive RT-PCR COVID-19 were hospitalized in the ICU. Two hundred fifteen (48.6%) were mechanically ventilated and met the inclusion criteria. Patients' characteristics were: mean age, 65 ± 12 years; male, 142(66%); median SAPSII on admission, 32 [26–38]; median SOFA on admission, 3 [1–4]; median IMV duration, 8 [4–12] days. The median length-of-stay was 11 [7–17] days. The overall mortality rate was 83%. Overall, 27(12.5%) patients developed VAP with density incidence rate estimated at 10.5 VAP/1000 ventilator days. The three identified periods were respectively, February–October 2020 (9 months) November 2020–April 2021 (6 months); and May–September 2021 (5 months).VAP frequencies were respectively, 6(28.5%), 12(11.3%) and 9(10.2%) at stages 1, 2 and 3. Patients with VAP had significantly longer duration of IMV (9[5–13] vs 7[4–11] days, p = 0.007), longer length of ICU stay (12[8–17] vs 10[7–16] days, p = 0.007), higher mortality rate (98.5% vs 79.5%, p = 0.027) and lower extubation rate (1.5% vs 31%, p = 0.001). The most frequently isolated microorganism was *Acinetobacter baumanii* 12(44%), followed by *Pseudomonas aeruginosa*, 7(26%); *Klebsiella pneumonia*, 4(14.8%) and *Candida albicans*, 2(7.4%). The only risk factor independently associated with VAP was the duration of IMV (RR, 1.15; 95% CI, [1.04–1.27]; p = 0.006).

**Conclusion:** Mechanically ventilated COVID-19 patients had a high frequency of ventilator-associated pneumonia, varying according to protection measures. IMV duration was identified as independent risk factor for VAP.

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

FC-240

Impact of early steroids for COVID-19 related ARDS
on ventilator-associated pneumonia

LAMOUCHE-WILQUIN Pauline², SOUCHARD Jérôme¹, PERE Morgane²,
RAYMOND Matthieu², ASFAR Pierre³, DARREAU Cédric⁶, REIZINE Florian⁴,
HOURMANT Baptiste⁵, COLIN Gwenhaël⁵, RIEUL Guillaume¹, KERGOAT
Pierre⁸, FRÉROU Aurélien⁹, LORBER Julien¹³, AUCHABIE Johann¹⁰,
LACOMBE Béatrice¹³, SEGUIN Philippe⁴, EGRETEAU Pierre-Yves¹², MORIN
Jean², FEDUN Yannick¹, CANET Emmanuel², LASCARROU Jean-Baptiste²,
DELBOVE Agathe¹

¹CHBA Vannes, Vannes, France; ²CHU Nantes, Nantes, France; ³CHU Angers, Angers, France; ⁴CHU Rennes, Rennes, France; ⁵CHD Vendée, La Roche Sur Yon, France; ⁶Centre hospitalier du Mans, Le Mans, France; ⁷CHU Brest, Brest, France; ⁸Centre hospitalier de Cornouaille, Quimper, France; ⁹Centre hospitalier de St Malo, St Malo, France; ¹⁰Centre hospitalier de Cholet, Cholet, France; ¹¹CH Morlaix, Morlaix, France; ¹²CH Saint Nazaire, St Nazaire, France; ¹³Centre hospitalier Bretagne Sud, Lorient, France

**Correspondence:** Agathe DELBOVE (agathe.delbove@ch-bretagne-atlantique.fr)

Annals of Intensive Care 2022, 12(1):FC-240
**Rationale:** Few data of long-term outcome (including infectious complications) of early steroids course for COVID-19 related acute respiratory distress syndrome (ARDS) are available. This multicentric retrospective cohort study aims to determine the influence of an early course of steroids on ventilator-associated pneumonia (VAP) incidence in COVID-19 patients under mechanical ventilation (MV).

**Patients and methods/Materials and methods:** We included patients over 18 years old admitted in ICU for SARS-CoV 2 related ARDS under MV for at least 48 h in 15 ICUs. Inclusion period was from 1st January to 31st$^{th}$ December of 2020. Early steroid group (ESG) was defined by administration of corticosteroids within 24 h of admission whereas patients in control group (CG) did not receive corticosteroids within 24 h of admission. The main study outcome was VAP incidence. Secondary outcomes included day 90 mortality, MV duration, other organ dysfunctions and VAP characteristics.

**Results:** We included 670 patients of mean age 67 years-old, of whom 369 in ESG and 301 in CG. Sex ratio (73.9% male), rate of hypertension (55.2%) and diabetes (31.2%) was similar between groups. ESG was slightly older (mean age $66.7 \pm 10.2$ vs $63.5 \pm 11.3$ years-old, $p=0.0001$), had greater BMI ($30.4 \pm 6.0$ vs $28.9 \pm 5.4$ kg/m$^2$, $p=0.0007$), more immunosuppression ($20.3\%$ vs $10.6\%$, $p=0.0007$) and a greater Charlson score ($4.3 \pm 2.5$ vs $3.1 \pm 2.2$, $p<0.0001$). Mean $PaO_2/FiO_2$ ratio upon admission was $143 \pm 67$. The cumulative incidence of VAP with death and extubation as competing events was higher in ESG, with a Hazard Ratio (HR) of $1.29$ (CI95% [1.05; 1.58]), $p=0.016$. Antibiotic therapy was active on future identified bacteria on $80.8\%$ vs $74.6\%$ patients in ESG vs CG ($p=0.18$). Bacterial antibiotic resistance of VAP was not different (OR $0.94$, CI95% [0.58; 1.53]), $p=0.81$. In univariate analysis, there was no difference in day-90 mortality between groups with $30.9\%$ in ESG vs $24.3\%$ in CG ($p=0.111$). In a multivariate analysis, there was no difference in day-90 mortality in both group (HR $1.15$, CI95% [0.83; 1.60], $p=0.411$). VAP was associated with a higher day-90 mortality (HR $1.63$; CI95% [1.17; 2.28], $p=0.0003$). Each increase of 1 years-old (HR $1.05$, CI95% [1.03; 1.07]), $p<0.001$) and increase of 1 point of SOFA score (HR $1.15$, [1.09;1.22], $p<0.0001$) were also associated with an increase of mortality.

**Conclusion:** In this retrospective study, early use of steroids was associated with an increased risk of developing VAP in mechanically ventilated COVID-19 patients. Risk of death was higher in presence of VAP, but day-90 mortality did not reach statistical difference between groups. These results suggest VAP associated mortality could counterbalance steroids benefits in this population.

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

## FC-241
### Prolonged antimicrobial treatment over than 7 days is associated with lower recurrence of VAP in patients with COVID-19 related ARDS

GAVAUD Ariane¹, TERRACOL Laura¹, BOUGHDIRI Ahmed², CANOUI Etienne¹, CHARPENTIER Julien¹, POUPET Hélène¹, POYART Claire¹, MIRA Jean-Paul¹, GASTLI Nabil¹

¹Hôpital Cochin, Paris, France; ²Ecole des Ponts, Champs-Sur-Marne, France

**Correspondence:** Ariane GAVAUD (ariane.gavaud@gmail.com)

Annals of Intensive Care 2022, **12**(1):FC-241

**Rationale:** Patients hospitalized in the intensive care unit (ICU) for COVID-19 related acute respiratory distress syndrome (ARDS) are at high risk for recurring ventilator-acquired pneumonia (VAP), that are associated with poor outcome. The aim of this study was to describe characteristics of first episode and recurrences of VAP along the 3 first epidemic waves, and to identify determinants involved in the recurrence, including host, microbiological and treatment factors.

**Patients and methods/Materials and methods:** We conducted a retrospective observational study in a 24-bed ICU between March 2020 and May 2021. All adult patients admitted for severe COVID-19

pneumonia requiring >48 h of mechanical ventilation were consecutively included. VAP episodes were diagnosed using clinical, radiological and quantitative microbiological criteria. VAP recurrence was defined as reappearance of VAP criteria after antibiotic discontinuation, with at least one bacterial species growing at a significant concentration from a new respiratory sample. Recurrence was considered a "relapse" if at least one of the initial causative bacterial strains grew at a significant concentration from a second distal sample; otherwise, it was considered a "superinfection". Among patients with first episode of VAP, we investigated determinants associated with recurrence using logistic regression analysis with Cox-model. Primary outcome measurement was ICU discharge without VAP recurrence.

**Results:** Of 154 included patients, 115 (75%) presented a first episode of VAP. At least one recurrence occurred in 64/97 (66%) patients who survived from the first episode, with same pathogen in 49/64 (76%) patients (relapse). Enterobacteriaceae (56%) and *Staphylococcus aureus* (37%) were the most frequently isolated in the first episode, while recurrences recovered mainly Enterobacteriaceae (67%) and non-fermenting Gram-negative bacteria (53%). Infection with Methicillin-susceptible *S. aureus* was associated with an increased risk of recurrence within 7 days after antimicrobial treatment interruption (HR for absence of recurrence: 0.3 [0.1–0.9]) compared with other pathogens. The ICU mortality was 32% in our study population. Among patients who survived the first episode of VAP, recurrence was correlated with poorer outcome (mortality of 34% vs 9% if no recurrence; $P=0.006$) Prolonged duration of antimicrobial treatment (> 7 days), as well as appropriate empiric antimicrobial treatment were associated with an increased probability of ICU discharge without VAP recurrence: HR 7.3 [2.2–24.1] and HR 2.7 [1.0–7.0].

**Conclusion:** In COVID-19 related ARDS patients treated for first VAP episode, prolonged duration of antimicrobial treatment may be a possible key to reduce VAP recurrences and have a beneficial impact on prognosis in ICU.

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

<figure><img src="image_103.png" /></figure>

Factors associated with discharge of ICU without recurrence of VAP

## FC-242
### Procalcitonin kinetics as a prognostic marker of ventilator-associated pneumonia

AQUIN Camille¹, VIGNERON Clara², CHARBONNEAU Philippe³, TRINH Vincent Quoc Huy⁴, QUENOT Jean-Pierre¹, CHARLES Pierre-Emmanuel¹

¹Centre Hospitalier Universitaire, Dijon, France; ²Hôpital Cochin, Paris, France; ³Centre Hospitalier de l'Université de Montréal, Montréal, Canada;

⁴Vanderbilt University Medical Center, Nashville, Etats-Unis

**Correspondence:** Camille AQUIN (camiaquin@yahoo.fr)

Annals of Intensive Care 2022, **12**(1):FC-242

**Rationale:** Ventilator-associated pneumonia (VAP) is a common and serious infection that is often difficult to diagnose. Biomarkers have been proposed as a diagnostic tool. The assay of procalcitonin (PCT) is not recommended for diagnostic purposes, but numerous studies have shown its prognostic value. The use of the kinetics, rather than an absolute value, seems more relevant.
**Patients and methods/Materials and methods:** Patients with an episode of VAP between December 2005 and October 2017 were identified. After excluding the missing data, 518 patients were included and divided into three groups according to their procalcitonin kinetics between D2 and D3 (Group 1: ΔPCTD2-D3 ≥ 30%; group 2: ΔPCTD2-D3 = [1-29%]; group 3: ΔPCTD2-D3 ≤ 0%).

**Results:** The 1st group (148 patients) had a 28-day mortality of 29,7%, the 2nd group (212 patients) of 42,9%, and the 3rd group (158 patients) of 50,6%. Mortality was greater in group 3, after univariate (p = 0.001) and multivariate (p = 0.014) analysis. Multivariate analysis identified age, cirrhosis, chronic renal failure, and belonging to group 3, as independent factors associated with mortality.

**Conclusion:** Our study suggests that the kinetics of procalcitonin between the following day and two days after the diagnosis of VAP (D2-D3) may be a prognostic marker of mortality. The identification of factors associated with mortality could allow the early identification of patients at risk in order to optimize their management.

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

FC-243

Volume variation of endotracheal aspirates to predict onset of ventilator-associated pneumonia

DANCHE Estelle¹, MEYER Sylvain¹, GUICHARD Elie², HERNANDEZ PADILLA Ana Catalina¹, FEDOU Anne-Laure¹, VIGNON Philippe¹, BARRAUD Olivier¹, FRANÇOIS Bruno¹

¹CHU Dupuytren, Limoges, France; ²CHRU de Tours, Tours, France

**Correspondence:** Estelle DANCHE (estelle.danche@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-243

**Rationale:** Ventilator-associated pneumonia (VAP) is the most common cause of infection in the ICU but its diagnosis remains challenging. In this context, the CPIS, one of the most universal VAP score may help. Most of its component may be modified by "external factors" and therefore CPIS is in fact neither very specific neither very sensitive. Endotracheal secretions are one of the clinical criteria used for the diagnosis of VAP in CPIS and European and American guidelines. However, few studies analyzed the properties of those secretions, and their dynamics during mechanical ventilation. We hypothesized that endotracheal secretions volume modifications could help to early identify patients developing VAP.

**Patients and methods/Materials and methods:** We conducted a prospective study in adult patients requiring mechanical ventilation (MV) for at least 7 days. Included patients had to be free from acute or chronic pulmonary disease and from any acute infectious disease or antibiotic treatment before inclusion. Mostly neurological patients, including trauma were targeted to have a "very clean" population. Patients were included from intubation and all endotracheal secretions collected as part of routine care by bedside nurses were collected until D7. Daily secretions volume and appearance were measured as well as all CPIS components. All VAP events were retrospectively validated by a blinded adjudication committee. We analyzed the progression of CPIS during the first week of ventilation, and the variations in volume aspirates to identify different group pattern. Descriptive statistics were used to describe the study cohort. Spaghetti plot was used to visualize individual trajectories according to the VAP events.

**Results:** Forty-eight patients were analyzed [28 men; 58 (±15) years old, BMI 26.4 (±6.6) kg/m², Apache II score 14.3 (±5.3), Charlson Comorbidity Index of 2.8 (±1.9)]. Ten (21%) patients developed VAP and 1556 ETA samples were analyzed. Although the volume aspirate tends to increase during mechanical ventilation in all patients (figure), we did not find differences between patients with or without VAP, and no pattern could be identified. The mean and standard deviation of volume aspirate for patients without VAP being high, it covered the value of patient with VAP. Concerning the CPIS, our study shows the absence of relevance of the CPIS, independently from the infectious status.

**Conclusion:** Our study did not permit to identify pattern for patients at risk of VAP, using the daily volume aspirate or the CPIS.

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

<figure><img src="image_104.png" /></figure>

Kinetics of daily volume aspirate during the first 7 days of ventilation.
Coloured lines: patients who developed VAP (stops the day before VAP)
Dashed and black lines: the mean ± the standard deviation for the
patients without VAP.

FC-244

Serial measurements of serum procollagen III and hyaluronic acid correlate with lung fibroproliferation during COVID-19 associated acute respiratory distress syndrome

ALLARDET-SERVENT Jerome¹, DEHAENE Aurelie¹, PLAUZOLLES Anne⁴, SOMMA Claude², BOURLARD Donatienne⁶, SECQ Veronique³, BOUAMRA Yannis⁵, KHIRI Hacene⁴, FOREL Jean-Marie³, D'JOURNO Xavier Benoit³

¹HOPITAL EUROPEEN MARSEILLE, Marseille, France; ²HOPITAL DE LA TIMONE, Marseille, France; ³HOPITAL NORD, Marseille, France; ⁴LABORATOIRE ALPHABIO, Marseille, France; ⁵LABORATOIRE EUROFINS BIOMNIS, Ivry Sur Seine, France; ⁶LABORATOIRE EUROFINS PATHOLOGIE, Marseille, France

**Correspondence:** Jerome ALLARDET-SERVENT (j.allardetservent@hospital-european.fr)

Annals of Intensive Care 2022, 12(1):FC-244

**Rationale:** Fibroblastic proliferation with organizing fibrosis occurred in the late stage of COVID-19 related acute respiratory distress syndrome (CARDS)¹. Monitoring lung fibroproliferation would help to timely introduce rescue corticosteroids therapy (CST). This study investigates the value of serial measurements in serum of three extracelular matrix (ECM) biomarkers to detect lung fibroproliferation during CARDS².

**Patients and methods/Materials and methods:** Five patients with lung fibrosis following CARDS were studied. All patients had reticulations and bronchiectasis on CT scans and three had lung biopsy with confirmed histologic fibrosis. Three patients who underwent elective thoracic surgery and had normal preoperative lung function served as controls. The concentrations of amino-terminal propeptide of type I and type III procollagens (PINP, PIIIINP) and hyaluronic acid (HA) were measured weekly using radioimmunoassay (UniQ® RIA, Aidian Oy, Espoo, Finland) and immunoturbidimetric method (HA LT, FUJIFILM Wako Chemicals, Neuss, Germany). A PIIIINP level above 16 µg/L indicated high probability of lung fibrosis². Cut-offs for PINP and HA have not yet been established. Comparisons were performed using Mann-Whitney U test and correlation with the Rho Spearman's test. Data are presented as median and interquartile.
**Results:** The five fibrotic patients were mostly male (80%), aged 58 [52,70] years, and had normal respiratory function prior admission. All received mechanical ventilation with a median duration of 37 [32,71] days and three required veno-venous extracorporeal membrane oxygenation during 20 [13,21] days. Only one patient survived (Case F-5). The average concentrations of PIIINP and HA over the stay were higher in fibrotic patients compared to controls, respectively 14 [9.2, 22] vs. 2.5 [2.2, 4] µg/L (p=0.005) and 311 [143, 699] vs. 37 [22, 80] µg/L (p=0.007). In contrast, PINP did not differ between cases (37.5 [21, 53] µg/L) and controls (40 [19.8, 44.5] µg/L; p=0.64). Figure 1 displayed the time course of biomarkers in fibrotic individuals. The time-weighted average concentrations of PIIINP and HA correlated with the amount of histologic lung fibrosis (respectively p=0.749, p=0.032 and p=0.687, p=0.059). Serum PIIINP levels overcrossed the predefined fibrosis threshold in all cases within a median delay of 16 (14,25) days.

**Discussion:** This proof-of-concept study is the first to describe the course of three ECM biomarkers in the serum of patients with CARDS related lung fibrosis. Only PIIINP and HA exhibited dynamic variations, increased average concentrations and correlated with histologic fibrosis. PIIINP levels exceeded the predefined fibrosis threshold in all fibrotic patients.

**Conclusion:** The non-invasive monitoring of lung fibroproliferation using serial measurement of PIIINP in serum represents a promising strategy and warrants larger investigations.

**Reference 1:** Carsana, L et al. Pulmonary Post-Mortem Findings in a Series of COVID-19 Cases from Northern Italy: A Two-Centre Descriptive Study. The Lancet Infectious Diseases 2020, 20 (10), 1135–1140.

**Reference 2:** Forel, J.-M et al. Type III Procollagen Is a Reliable Marker of ARDS-Associated Lung Fibroproliferation. Intensive Care Med 2015, 41 (1), 1–11.

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

<figure><img src="image_105.png" /></figure>

Time course of serum biomarkers concentration among the five CARDS related fibrotic patients. A: PINP (dashed line) and PIIINP (solid line). B: Hyaluronic acid (HA). C: Daily dose of corticosteroid therapy (CST) expressed as methylprednisolone equivalent.

FC-245

Impact of extent parenchymal lesions on critically ill COVID-19 patient outcomes

ALILA Ilef¹, KHARRAT Sana¹, BOUBTANE Rihab¹, TURKI Olfa¹, HAFDHI Malek¹, BAHLOUL Mabrouk¹, BOUAZIZ Mounir¹
¹hospital Habib Bourguiba Sfax, Sfax, Tunisie

**Correspondence:** Ilef ALILA (ilefalila1323@gmail.com)
Annals of Intensive Care 2022, **12**(1):FC-245

**Rationale:** During the COVID-19 pandemic, thoracic computed tomography (CT) has proven to be a useful tool not only for diagnosis but also for assessing the extent of SARS-COV2 lesions and detecting possible thoracic complications. The aim of our study was to assess the risk of death or use of invasive mechanical ventilation (IMV) in patients hospitalized with SARS-COV2 pneumonia according to the percentage of lung parenchymal injury.

**Patients and methods/Materials and methods:** This was a retrospective study conducted in a medical intensive care unit for 16-month period from September 2020 to December 2021. Patients hospitalized with SARS-COV2 pneumonia who received a chest CT scan within the first 48 h of their stay in the ICU were collected.

**Results:** This study included 440 COVID-19 patients, with a mean age of 59.7 ± 14.3 years and a male predominance (sex ratio = 1.75). On admission, 328 patients had severe acute respiratory distress syndrome (ARDS) (74.5%) Invasive mechanical ventilation was required in 196 (44.5%) patients and overall mortality was of 48% (210 patients). Severe lung damage ranging among 75% of the lung parenchyma was estimated in 117 patients (26.6%), of which 99 patients had severe ARDS on admission (85%), 62 patients had required mechanical ventilation (53%; p=0.036), and 64 had developed infections during hospitalization (55%, p=0.036). Comparison between patient outcomes according to the extent of parenchymal lesions on CT is shown in Table I.

**Conclusion:** Initial quantitative assessment of COVID-19 lesions may predict severity and outcomes in patients admitted with SARS-COV2 pneumonia.

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

<table><thead><tr><th rowspan="2">Parameters</th><th colspan="4">Estimated pulmonary damage on CT</th><th rowspan="2">P</th></tr><tr><th>« 0-25% »<br>n=33</th><th>« 25-50% »<br>n=115</th><th>« 50-75% »<br>n=175</th><th>« >75% »<br>n=117</th></tr></thead><tbody><tr><td>Severe ARDS, n(%)</td><td>20 (61)</td><td>68 (59)</td><td>141 (81)</td><td>99 (85)</td><td><strong>&lt;0.001</strong></td></tr><tr><td>IMV, n(%)</td><td>19 (58)</td><td>47 (41)</td><td>68 (39)</td><td>62 (53)</td><td><strong>0.036</strong></td></tr><tr><td>Vasopressor, n(%)</td><td>16 (48)</td><td>41 (36)</td><td>58 (33)</td><td>57 (49)</td><td><strong>0.30</strong></td></tr><tr><td>Infection, n(%)</td><td>16 (48)</td><td>43 (37.4)</td><td>71 (40.6)</td><td>64 (55)</td><td><strong>0.036</strong></td></tr><tr><td>Décès, n(%)</td><td>15 (45)</td><td>51 (44.3)</td><td>77 (44)</td><td>67 (57)</td><td><strong>0.12</strong></td></tr></tbody></table>

ARDS: Acute respiratory distress syndrome; IMV: invasive mechanical ventilation

<caption>Table I: Patient outcomes according to CT extent of parenchymal lesions COVID-19</caption>

FC-246

Are CT-scan severity scores accurate in predicting outcome in ICU COVID-19 patients: a cohort validation

MAATOUK Syrine¹, LAHMAR Manel¹, HAMMOUDA Zeineb¹, SAAD Jamel¹, BETBOUT M¹, ZRIG Ahmed¹, ABROUG Fekri¹, BESBES Lamia¹
¹CHU Fattouma Bourguiba Monastir, Monastir, Tunisie

**Correspondence:** Syrine MAATOUK (syrinemaatouk@gmail.com)

Annals of Intensive Care 2022, **12**(1):FC-246

**Rationale:** Several chest CT severity scores have been developed during the covid-19 pandemic. These scores were usually higher in patients with critical disease compared to those with less severe disease. The aim of this study is to compare the performance of two CT scoring methods in predicting the risk of intubation in patients initially managed with non-invasive ventilation (usually High Flow Nasal Oxygenation (HFNO)).

**Patients and methods/Materials and methods:** A single-center prospective analysis conducted during a 5-months period (from September 2020 to January 2021). All patients admitted to ICU with RT-PCR confirmed covid-19 infection and requiring HFNO as a respiratory support were included. All CT-scan images were analyzed according to two scores. The first one was widely used during the pandemic, gives precedence to the extension of the lesions, an extension expressed in a semi-quantitative way (<25%, 25–50%, 50–75%, >75%) and gives less importance to the nature of the lesions or their distribution, in particular in the antero-posterior dimension. The second score is an older one, first proposed during the H1N1 epidemic, and later on applied in several studies on ARDS. It divides each of the two lungs into 6 quadrants with 3 anteroposterior and longitudinal divisions. Weighing is assigned according to location and type of lung injury. This score ranges from zero to 72. We compared the performance of