Bispectral index and suppression ratio are very early predictors of neurological outcome during therapeutic hypothermia after cardiac arrest

To evaluate the bispectral index (BIS) and suppression ratio (SR) as very early predictors of neurological outcome during therapeutic hypothermia after cardiac arrest.Demographic data, BIS1, and SR1 were recorded from 97 patients after the first dose of neuromuscular blockade, with outcomes blinded, and compared to the discharge Cerebral Performance Category (CPC). Receiver-operator characteristic curves and a multiple logistic regression model were constructed to predict good (CPC 1-2, GO) and poor (CPC 3-5, PO) neurological outcomes.Fourteen patients were excluded from the final analysis; 33 of the remaining 83 patients (40%) were classified as GO. The BIS1 was higher in patients with GO (37 [28-40] vs. 7 [3-15], p < 0.001). BIS1 < 22 predicted PO with a likelihood ratio (LR) of 14.2 and an area under the curve (AUC) of 0.91 (95% CI 0.85-0.98, p < 0.001). SR1 > or =48 predicted PO with a LR of 12.7 and an AUC of 0.90 (95% CI 0.83-0.98, p < 0.001). Both BIS1 (DeltaAUC 0.16, p = 0.006) and SR1 (DeltaAUC 0.16, p = 0.005) predicted outcomes better than the time to return of spontaneous circulation.In our single-center cohort utilizing moderate sedation, the bispectral index and suppression ratio recorded after the first dose of intermittent neuromuscular blockade were accurate and very early predictors of neurological outcome during therapeutic hypothermia after cardiac arrest.

section_content: Introduction It has been previously shown that the two forms of acute cholecystitis, acute acalculous cholecystitis (AAC) and acute calculous cholecystitis (ACC), have significantly different histopathological features suggesting that AAC is a manifestation of systemic critical illness whereas ACC is a local disease of the gallbladder. A balance between cell proliferation and cell death is essential for cell homeostasis. The purpose of this study was to compare the markers of apoptosis, cell proliferation, and expression of hypoxic-inducible factor alpha (HIF-1α) in AAC, ACC and normal gallbladders. Methods The AAC group consisted of 30 patients who underwent open cholecystectomy due to acute acalculous cholecystitis during their ICU stay. The ACC group consisted of 21 hospitalized patients who underwent cholecystectomy due to acute calculous cholecystitis. The control group consisted of nine samples taken from normal gallbladders extirpated during pancreatic tumor surgery. The immunohistochemical analysis was done according to the manufacturer's recommendations and they consisted of Ki-67 (proliferation), M30 (apoptosis) and HIF-1α antibodies. Cell proliferation and degree of apoptosis were expressed as the percentage of positive cells. HIF-1α expression was expressed as absent or weak (Score 1) or strong (Score 2). Results Apoptosis (median, 25th, 75th percentiles) was significantly increased in AAC 1. 3% (1. 0%, 3. 3%), P = 0. 001 and ACC 0. 93% (0. 40%, 3. 25%), P = 0. 011 compared with controls 0. 32% (0. 20%, 0. 40%). Proliferation rate was also significantly increased in AAC Introduction Extracellular release of ATP is an important modulator of immune response. ATP plasma concentration is increased in sepsis [1]. IFNγ plays a critical role in host defense by promoting Th1 phenotype and bacterial clearance. Low IFNγ levels are associated with the Th2 phenotype consistent with critical illness anergy [2]. It has been reported that 100 and 300 mM ATP increased LPS/PHA-stimulated IL-10 secretion in human blood [3]. Higher IL-10/IFNγ ratio shifts the immune phenotype from Th1 to Th2 response. We studied the effect of ATP on LPS-stimulated IL-10 and IFNγ secretion in a standardized ex-vivo whole human blood culture. Methods Venous blood from 10 healthy volunteers was drawn into tubes containing 10 ng LPS/ml (ILCSÒ; EDI GmBH, Reutlingen, Germany) and incubated with or without 100 mM ATP, respectively, at 37°C for 24 hours. The supernates were separated and frozen at -20°C. Cytokine levels were analysed on a robotic workstation (epMotion 5075; Eppendorf AG, Hamburg, Germany) in duplicate using the ELISA Cytokine kit (Luminex; Biosource Int., Camarillo, CA, USA). Results Added ATP reduced the mean concentration of IFNγ in LPSstimulated blood from 1,206 ± 1,667 pg/ml to 140 ± 128 pg/ml; P = 0. 006. There was no consistent effect of ATP on IL-10 secretion in our study (21. 6 ± 16. 9 pg/ml to 17. 2 ± 18. 8 pg/ml). Interestingly, three subjects of Indian/Indonesian origin had IL-10 levels below the assay detection limit. The mean IL-10/IFNγ ratio was increased from 0. 05 ± 0. 04 to 0. 16 ± 0. 09 in the remaining Caucasian subjects (P = 0. 015). See Figure 1. Conclusions Our results suggest an immunosuppressive effect of extracellular ATP that is evident by the decrease of IFNγ and therefore the relative shift of the immune response towards Th2 phenotype. Although this may represent a self-protective mechanism, it may contribute to critical illness anergy.

section_content: Introduction Cardiac dysfunction is a feature of sepsis. In order to gain insight into the fundamental mechanisms of this phenotype, gene expression analysis (Affymetrix) was applied to serial cardiac biopsies of sham (n = 2) and E. coli infected pigs (n = 3). Methods Cardiac samples were taken basal and hourly after infection for gene analysis and at the end of the experiment for histopathological examination. Genes were determined to be differentially regulated at a greater than or less than twofold change and P < 0. 05. Results Sham pigs had stable heart rate, cardiac output (CO) and core temperature for the 5-hour period; infected pigs demonstrated an early elevation in CO and ventricular shortening and/or ejection (assessed by echocardiography) followed by development of hypodynamics. In infected animals, increasing numbers of genes were upregulated or downregulated (36, 278, 514, 842 and 1,238 at 1, 2, 3, 4 and 5 hours) (Figure 1 ) whereas sham infection altered fewer (247, 67 and 384 genes at 2, 3 and 4 hours). Comparing sham vs infected animals at the same time, numbers of significantly altered genes increased with time (32 at basal, to 74, 189 and 601 at 2, 3 and 4 hours post infection). In hematoxylin-eosinstained sections, histopathological assessment revealed acute inflammation in pericardium and myocardium in infected pigs. Conclusions These results will provide biomarker and mechanistic insights to pathogenesis of cardiac dysfunction of septic peritonitis and may also help identify some altered novel gene transcription pathways that can serve as new targets for diagnostic tools and therapeutic strategies. All candidate genes will be validated by quantitative PCR. associated with proximal tubule injury. In several in vitro and animal studies alkaline phosphatase (AP) was found to be effective in attenuating the inflammatory response by dephosphorylating LPS and may prevent organ damage. The objective of this study was to investigate the effect of AP on renal iNOS expression and kidney damage in patients with severe sepsis or septic shock. Fifteen patients (nine male/six female, age 55 ± 5 years) with Gram-negative bacterial infection, two out of four SIRS criteria (<24 hours) and acute onset of end-organ dysfunction (<12 hours) were included in a randomized, double-blind, placebo-controlled phase IIa study (2:1 ratio). An intravenous bolus injection of 67. 5 U/kg bovine intestinal AP was followed by a maintenance dose of 177. 5 U/kg for 24 hours. Arterial blood and urine were collected at different time points and analyzed for stable metabolites of NO. iNOS mRNA was determined by quantitative real-time RT-PCR using RNA isolated from renal cells in urine. The urinary excretion of the cytosolic glutathione S-transferase-A1 (GSTA1-1), a marker for proximal tubule damage, was measured using an ELISA. Data are depicted as the median (25-75% range). NO metabolites in blood were not significantly different between AP-treated (n = 10) and placebo-treated (n = 5) patients. However, the urinary excretion of NO metabolites decreased by 80% (75-85) from 227 (166-531) at baseline to 41 (28-84) µmol/ 10 mmol creatinine (P < 0. 05) after 24 hours of AP administration. After placebo treatment, the amount of urinary NO metabolites increased by 70% (45-570) (from 81 (64-419) to 628 (65-1,479) µmol/10 mmol creatinine, P < 0. 05). Baseline expression levels of iNOS in renal cells were 42-fold induced at baseline (vs healthy subjects), and AP administration reduced this induction by 80 ± 5% (Figure 1 ). Creatinine clearance improved by 45% (30-180) in patients treated with AP and declined by 25% (15-35) in placebo-treated patients. During the first 24 hours the amount of GSTA1-1 in urine of AP-treated patients decreased by 70% (50-80), compared with an increase of 200% (45-525) in placebo-treated patients, which correlated with urinary NO metabolites, indicating NO-induced proximal tubular damage. 

In conclusion, in septic patients, infusion of AP results in an attenuated upregulation of iNOS and, subsequent, reduced NO production in the kidney, associated with an improvement in renal function. 

Introduction Hypothermia was shown to attenuate ventilatorinduced lung injury (VILI) in high end-inspiratory lung volume models of VILI [1] [2] [3]. Experimental evidence suggests that moderate tidal volumes may, under certain clinical conditions that induce alveolar instability, lead to a lung injury [4]. Recent studies have also suggested that insults like shock [5] or surgery [6] sensitize the lung to injury by priming for an exaggerated response to a second stimulus. The aim of this study was to investigate whether moderate hypothermia attenuates low lung volume injury during low PEEP, high FiO 2 and moderate tidal volume ventilation in animals sensitized to injury by previous anesthesia and surgery. Methods Sixteen male adult Sprague-Dawley rats, instrumented under ether anesthesia with vascular catheters on the previous day, were anesthetized, tracheostomized, connected to a ventilator and randomly allocated to groups of normothermia (37 ± 0. 5°C, group N, n = 8) or hypothermia (33 ± 0. 5°C, group H, n = 8). After 2 hours of mechanical ventilation (FiO 2 1,0, respiratory rate 60/min, tidal volume 10 ml/kg, PEEP 2 cmH 2 O) inspiratory pressures were recorded, rats were sacrificed, the P-V curve of the respiratory system constructed, and bronchoalveolar lavage and aortic blood samples obtained. 

Results Group H animals exhibited in comparison with group N animals a lower increase in peak inspiratory pressures (0. 7 ± 1. 1 vs 2. 4 ± 0. 5 mmHg, P < 0. 001), significant shift of the P-V curve to the left and lower total protein (113 ± 42 vs 201 ± 97 µg/ml, P = 0. 047) and TNF (23. 5 ± 8. 0 vs 35. 2 ± 8. 5 pg/ml, P = 0,022) levels in BAL samples. Conclusion Moderate hypothermia attenuated lung injury during low PEEP, high FiO 2 and moderate tidal volume ventilation in animals sensitized to injury by previous anesthesia and surgery. Acknowledgement Supported by the Research project MZO 00179906. 

Introduction Glycocalyx (GLX) is implicated in mechanotransduction of shear stress and microvascular blood flow. We tested whether GLX loss accounts for the microvascular dysfunction in sepsis and whether activated protein C (APC) preserves endothelial GLX integrity. Methods Endotoxin LPS (10 mg/kg) was infused in rats treated or not with APC (240 µg/kg/hour). Changes in GLX were assessed by circulating levels of hyaluronan (a GLX constituent) and by GLX apparent thickness evaluated using intravital microscopy by comparing 4 and 150 kDa dextran distribution as markers of GLX permeable and impermeable tracers, respectively. Intravital microscopy was used to characterize mesentery functional capillary density. Because glycocalyx is extremely sensitive to free radical, oxidative stress was evaluated by oxidation of dihydrorhodamine (DHR) in microvascular beds and by concentrations of heart malondialdehyde (MDA) and plasma carbonyl proteins (CP). 

Results LPS elicited a 4 hours later profound reduction in GLX layer thickness and increase in plasma hyaluronan levels. LPS rats had decreases in capillary continuous flow, and significant increases in intermittent and stopped flow capillaries compared with controls. 

The pressor responses to norepinephrine were greatly reduced, indicative of vascular hyporeactivity. In vivo oxidation of DHR and levels of heart MDA and plasma CP were all increased in LPStreated rats. Interestingly, in LPS rats, APC reduced plasma hyaluronan levels and GLX destruction, which was accompanied with major improvements in vasopressor response and functional capillary density. APC treatment also prevented increases in biochemical and in vivo microvascular oxidative stress markers.
section_name: Figure 1 (abstract P5)

section_content: In our model of septic shock, increased plasma hyluronan levels and reduction in endothelial layer thickness indicated GLX degradation. APC prevented vascular oxidative stress and limited GLX loss. GLX degradation plays a critical role in the septic vasculature and generation of free radicals during septic shock is potentially toxic to GLX function.
section_name: Conclusion

section_name: P20

section_content: after catheter insertion into subcutaneous adipose tissue (SAT) of patients with severe sepsis compared with healthy volunteers. Methods Eight healthy volunteers and 10 patients with severe sepsis were included. One 18-gauge open-flow microperfusion double-lumen catheter was inserted into SAT of the abdominal wall and perfused with an isotonic solution at a flow rate of 1 µl/min. Blood samples and probe effluent samples from interstitial fluid of SAT were withdrawn in two hourly intervals for a period of 8 hours and retrospectively analysed using a Multiplex ELISA system for IL-1β, IL-6, IL-8 and TNFα. 

Results Concentrations of IL-1β, IL-6 and IL-8 were substantially higher in SAT (13. 3 (11. 2; 31. 0); 1,934 (1,650; 2,730); 917 (656; 2,672) pg/ml; median (25th; 75th percentile)) than in serum (0. 8 (0. 6; 1. 3); 49. 2 (3. 8; 67. 6); 36. 1 (6. 3; 89. 1) pg/ml) for both groups, whereas TNFα concentrations were similar in serum and SAT (Figure 1 ). Serum concentrations of all cytokines remained stable over time. However, a significant increase was observed for IL-1β and IL-8 in SAT in both groups. This increase was significantly in septic patients vs healthy controls. Conclusion Insertion of a catheter into subcutaneous adipose tissue promotes a local inflammatory response in both healthy individuals and critically ill patients. The attenuated response in patients with severe sepsis might be caused by reduced inflammatory reactivity in this group.
section_name: S9

section_content: The evaluation of sivelestat sodium hydrate in acute lung injury/acute respiratory distress syndrome patients in the intensive care unit T Ikeda, K Ikeda, T Ueno, Y Kuroki, T Yokoyama, K Yoshikawa Hachiouji Medical Center, Tokyo Medical University, Tokyo, Japan Critical Care 2007, 11(Suppl 2):P22 (doi: 10. 1186/cc5182)

The onset mechanism of ALI/ARDS and subsequent tissue injury are considered to be associated with neutrophil elastase, and the main causes of ALI/ARDS are considered to be sepsis or aspiration pneumonia. In Japan, sivelestat sodium hydrate (Elaspol), a selective elastase inhibitor, was approved in 2002 for ALI/ARDS accompanied by SIRS, and this medicine has been evaluated in a clinical situation. In this study, we performed a retrospective comparison of the sivelestat sodium administration between two groups of patients: Group Elaspol, consisting of 308 patients(209 males and 99 females, aged 66 ± 15 years) with ALI/ARDS accompanied by SIRS who were treated with sivelestat sodium at a dose of 0. 2 mg/kg/hour for 72 hours or more, after approval of this drug; and Group Control, consisting of 41 patients (28 males and 13 females, aged 66 ± 14 years) with ALI/ARDS accompanied by SIRS who were treated in the ICU under similar conditions, but using traditional methods for respiratory control, prior to approval sivelestat sodium. The APACHE II scores of Group Elaspol and Group Control were 23 ± 9 and 23 ± 8, SOFA scores were 8. 7 ± 3. 8 and 8. 9 ± 4. 1, and the lung injury scores were 2. 1 ± 0. 7 and 2. 1 ± 0. 6, respectively, with no significant differences between the groups. The initial PEEP value of Group Elaspol was 5. 9 ± 3. 3, which was significantly higher than that of Group Control (3. 4 ± 2. 7 cmH 2 O). The PaO 2 /FIO 2 ratios under mechanical ventilation management 24, 48 and 72 hours after the beginning of drug administration were 209 ± 87, 222 ± 92, and 222 ± 82 mmHg in Group Elaspol, and were 191 ± 91, 207 ± 91, and 211 ± 100 mmHg in Group Control. The ventilator-free days of Group Elaspol and Group Control were 18 ± 9 and 10 ± 12 days, respectively, and these values showed a significant difference (P < 0. 001). Furthermore, the survival rate after 28 days was significantly higher in Group Elaspol than in Group Control (Group Introduction Many patients who experience surgical stress including burn injury become susceptible to severe sepsis and septic organ dysfunction including acute lung injury (ALI), which remains the primary contributor to morbidity and mortality in burn patients. Proinflammatory cytokines including several chemokines are implicated in this process. The pharmacological modulation with steroid inhibiting the process of cytokine synthesis may serve as effective therapy for the prevention of tissue injury and the resultant organ dysfunction including respiratory failure. We developed a murine model of septic ALI after burn insult and examined the effects of prolonged administration of moderate doses of steroid. Methods Male BALB/c mice were divided into three groups. Group I served for sham burns. In groups II and III, a 15% BSA fullthickness burn was made on the dorsum under ether anesthesia, followed by adequate fluid resuscitation. After the burn injury, 3 mg/kg prednisolone (PSL) in group III was administered subcutaneously daily for 10 days. On the 11th day, 10 mg/kg lipopolysaccharide (LPS) was injected intravenously. In the first experiment, we observed the survival within 72 hours after LPS injection in each group (n = 10). In the second experiment, we sacrificed the animals at 12 hours after LPS injection, then obtained plasma and lung tissue to determine the levels of TNFα and macrophage inflammatory protein-2 (MIP-2, a functional homologue of human IL-8 in mice) in these samples (n = 8, sandwich ELISA). We also determined gene expression (n = 4, MIP-2/GAPDH mRNA ratio by RT-PCR), myeloperoxidase activities (MPO, n = 8) and histopathological findings in the lung tissue.
section_name: P22

section_content: The survival and production of cytokines are shown in Table 1. Histopathological findings in group III were obviously attenuated. Introduction Lethal sepsis occurs if an excessive inflammatory response evolves that cannot be controlled by physiological anti-inflammatory mechanisms. Vagus nerve stimulation showed improved survival in sepsis; however, this seems not to be feasible in septic patients. We therefore investigated the effect of activation of the cholinergic anti-inflammatory pathway by pharmacologic cholinesterase inhibition on survival and inflammation in a septic mouse model. Methods To investigate the therapeutic effect of nicotine and physostigmine we performed cecal ligation and puncture (CLP) in female C57/B6 mice (each group n = 21). Substances were administered by intraperitoneal injection. Control groups received the same volume (50-180 µl) of LPS-free 0. 9% NaCl (solvent). CLP was performed blinded to the identity of the treatment group. 

In addition to survival experiments we performed measurements of cytokines in plasma and the electrophoretic mobility shift assay (EMSA) for NF-κB in peritoneal skin, liver and kidneys. 

Results (1) Animals treated with nicotine (400 µg/kg) or physostigmine (80 µg/kg) survived significantly better than control mice (P < 0. 05). There was no difference between the treatment groups. 

(2) Dose escalation of physostigmine was not superior to the normal dose. Survival in the high-dose group, however, was still significantly better than in the control group. (3) Proinflammatory cytokine levels of TNFα, IL-6 and IL-1β were significantly reduced in animals treated with physostigmine (P < 0. 01). ( 4 ) Cholinesterase inhibition with physostigmine in CLP reduced NF-κB activation in the peritoneum, kidney and liver compared with the control and sham-operated group (P < 0. 01).
section_name: Results

section_content: We show that pharmacological cholinesterase inhibition with physostigmine improves survival in experimental sepsis, most probably by activation of the cholinergic anti-inflammatory pathway. One possible mechanism is modulation of the NF-κB pathway. Therefore, cholinesterase inhibition may have important implications for treatment of sepsis.
section_name: Conclusion

section_content: Introduction High-mobility-group box protein 1 (HMGB1) is a highly conserved, ubiquitous protein present in the nuclei and cytoplasm of nearly all cell types and, secreted into the extracellular milieu, acts as a proinflammatory cytokine. The function of HMGB1 has been widely studied for sepsis and inflammation. HMGB1 was reported as a late mediator in endotoxic shock and was known as an abundant protein present in nuclei and cytoplasm and involved in maintaining nucleosome structure and regulation of gene transcription. Moreover, elevated, circulating levels of HMGB1 also have been described in a case of human hemorrhagic shock due to abdominal aortic aneurysm without evidence of infection. However, the relationship between HMGB1 and trauma has not been studied except for the report of a rat model of burn.
section_name: P26 Relationship between the presence of serum highmobility-group box protein 1 and the injury severity score in trauma patients

section_content: The study cases consisted of 20 trauma patients who were admitted to the emergency room by ambulance. 

As soon as they arrived in the emergency room, their blood sample were collected, centrifuged, and stored at -80°C. The serum Lung heat shock protein (HSP70) expression in glucosamine vs saline following cecal ligation and puncture. 

S11 serum HMGB1 (group A) and without the presence (group B). We therefore divided into two groups, high ISS group (≤25) and low ISS group (>25), and examined the relation with the serum HMGB1 level. 

Results Our data showed that the number in group A was nine cases and group B was 11 cases. The ISS of group A was significantly higher than that in group B (P = 0. 0013). The P value of group A was significantly lower than in group B (P = 0. 0131). 

The serum HMGB1 level of the >25 ISS group was significantly higher than in the ≤25 ISS group. Discussion These data suggest that HMGB1 seems to be a primary mediator of trauma-induced pathology. Because the ISS was significantly correlated with the presence of serum HMGB1, HMGB1 may be expressed in severe injuries and it may be a important parameter that indicates the severity of injury.
section_name: Materials and methods

section_content: Introduction While early aggressive fluid administration has been associated with improved outcome in sepsis [1], this approach may increase the risk of lung edema and abdominal compartment syndrome when capillary permeability is increased. The aim of this study was to test two different approaches of volume resuscitation in septic animals. Methods Thirty pigs were anaesthetized and invasively monitored (systemic and regional flows and pressures). They were randomized to control, moderate volume (C; n = 7), control, high volume (CH; n = 8), peritonitis, moderate volume (P; n = 8) and peritonitis, high volume (PH; n = 7). Peritonitis was induced by instillation of 1 g/kg autologous faeces dissolved in glucose solution. Ventilation was adjusted to maintain an arterial pO 2 >100 mmHg. Groups CH and PH received 15 ml/kg/hour Ringer's solution plus 5 ml/kg/hour HES 6%, whereas groups C and P received 10 ml/kg/hour Ringer's solution. If clinical signs of hypovolaemia were present, additional boluses of HES 6% (maximally 100 ml/hour) were given. The animals were treated and observed for 24 hours or until death. 

Results Cardiac output was higher in group PH as compared with the other groups (P < 0. 05), while mean arterial pressure was

Available online http://ccforum. com/supplements/11/S2 similar in all groups. While the oxygenation index (paO 2 /FiO 2 ) decreased in all groups, group PH had the lowest values after 6 hours and throughout the rest of the experiments (P < 0. 05) (Figure 1 ). Survival was lowest in group PH, followed by group P, while all animals in the control groups survived until 24 hours (Figure 2 ). Conclusion High-volume administration decreased oxygenation and survival in peritonitis but not in control animals. A high-volume approach may not be generally beneficial in abdominal sepsis.
section_name: P27 Beneficial effects of antiplatelet drugs in patients with community-acquired pneumonia and in endotoxin shock in mice

section_content: Introduction Fluid resuscitation is necessary in sepsis, but positive fluid balance may increase the risk of mortality. We tested the hypothesis that a volume resuscitation strategy may modify liver mitochondrial function and outcome. Methods Twenty-nine anesthetized pigs received for 24 hours either endotoxin or placebo, and either Ringer's lactate 10 ml/kg/hour or 15 ml/kg/hour + 5 ml/hour HES. Systemic and regional hemodynamics were measured. Liver mitochondrial state 3 and state 4 oxygen consumption were determined. Results Hepatosplanchnic oxygen delivery was similar in endotoxic pigs with high (2. 97 ± 1. 58 ml/min/kg) vs moderate volume administration (3. 06 ± 0. 6 ml/min/kg), but hepatosplanchnic VO 2 was lower in animals with high (1. 32 ± 0. 4 ml/min/kg) vs moderate volume administration (1. 75 ± 0. 3 ml/min/kg, P = 0. 019). Endotoxin high-volume pigs exhibited a decrease in state 3 respiration for complex I and complex II (not significant) in comparison with control high-volume and with endotoxin low-volume pigs (Figure 1 ). They also had an increased mortality rate during the 24-hour study period (60% vs 0% in controls). Conclusion A prolonged high-volume resuscitation approach during endotoxemia may be associated with impaired hepatosplanchnic oxygen consumption, liver mitochondrial dysfunction and high mortality. The impact of aggressive and prolonged volume administration on hepatosplanchnic oxygenation and mitochondrial function in human sepsis should be determined. Thirty anesthetized, spontaneously breathing, male Sprague-Dawley rats underwent SMAO for 60 minutes followed by reperfusion (4 hours). C1-esterase inhibitor (100 IU/kg, 200 IU/kg body weight) or saline (0. 9%) was given as a single bolus before reperfusion. Sham-operated animals (n = 10) without SMAO served as controls. Systemic hemodynamics were monitored continuously, arterial blood gases analyzed intermittently, and leukocyte/ endothelial interactions in the mesenteric microcirculation quantified at intervals using intravital microscopy. Ileal lipid-binding protein (I-LBP) levels were measured from serum samples with an ELISA at the end of the experiments. C1-INH restored microcirculatory perfusion of postcapillary venules to baseline levels in a dose-dependent manner and reduced leukocyte adhesion following SMAO/reperfusion to similar levels in both C1-INH-treated groups during reperfusion. Furthermore, C1-INH treatment efficiently prevented metabolic acidosis, and reduced the need for intravenous fluids to support blood pressure. Furthermore, I-LBP levels decreased in a dose-dependent manner, and were comparable with the levels of sham-operated animals at the end of the experiments. Survival rates were 100% in controls and after 200 IU/kg C1-INH, 90% after 100 IU/kg C1-INH, and 30% in saline-treated animals.
section_name: P29 Effects of volume resuscitation on hepatosplanchnic oxygen consumption, liver mitochondrial function and mortality in endotoxemia

section_content: In the setting of mesenteric ischemia, C1-INH given as a bolus infusion shortly before reperfusion efficiently restored microcirculatory perfusion in a dose-dependent manner, reduced local and systemic inflammatory response, and improved outcome. I-LBP levels correlated well with the functional consequences of mesenteric ischemia/reperfusion and treatment at the end of the experiments. 

Introduction Terlipressin is increasingly used in the treatment of sepsis-associated hypotension. However, terlipressin may reduce cardiac output and global oxygen supply. Methods We performed a prospective, randomized, controlled clinical study to determine whether dobutamine may counterbalance the depressions in cardiac index and mixed-venous oxygen saturation resulting from sole terlipressin infusion. We enrolled 60 septic shock patients requiring high doses of norepinephrine (0. 9 µg/kg/min) to maintain mean arterial pressure at 70 ± 5 mmHg. Patients were randomly allocated to be treated either with (a) 1 mg terlipressin, (b) 1 mg terlipressin followed by incremental dobutamine doses to reverse the anticipated reductions in mixed-venous oxygen saturation, or (c) sole norepinephrine infusion (control; each n = 20). 

Results Data from right heart catheterization, thermo-dye dilution catheter, gastric tonometry, as well as organ function and coagulation were obtained at baseline and after 2 and 4 hours. Terlipressin (with and without dobutamine) infusion preserved the mean arterial pressure at threshold values of 70 ± 5 mmHg, while allowing one to reduce norepinephrine doses to 0. 18 ± 0. 04 and 0. 2 ± 0. 05 µg/kg/min, respectively (vs 1. 4 ± 0. 07 µg/kg/min in controls at 4 hours; each P < 0. 01). The terlipressin-linked decrease in mixed-venous oxygen saturation was reversed by dobutamine (at 4 hours: 59 ± 2 vs 69 ± 3%, P = 0. 023). No statistically significant differences were found intra-group and between groups in terms of differences between gastric mucosal and arterial carbon dioxide partial pressure, blood clearance of indocyanine green, as well as the plasma disappearance rate of indocyanine green Conclusions In catecholamine-dependent human septic shock, terlipressin (with and without concomitant dobutamine) stabilizes hemodynamics and reduces norepinephrine requirements. Dobutamine is a useful inotropic agent to reverse the depression in global oxygen transport resulting from sole terlipressin infusion without obvious side effects.
section_name: P30

section_content: We tested the effects of arginine vasopressin on tissue oxygenation, microvascular reactivity and oral mucosa microcirculation in patients with septic shock. Methods In 20 patients with septic shock, tissue microcirculation was determined before treatment with AVP (2 IU/hour), after 2 hours of treatment and 2 hours after treatment. 

The thenar muscle StO 2 was measured by near-infrared spectroscopy (InSpectra; Hutchinson Technology, Hutchinson, MN, USA). Oral mucosal tissue oxygen saturation, microcirculatory blood flow and blood flow velocity were measured in depths of 1 and 4 mm with a laser Doppler flowmetry and remission spectroscopy system (O 2 C). 

Results See Table 1. Vasopressin infusion led to a significant decrease of oral mucosal oxygen saturation and blood flow, and a significant decrease of flow velocity in a depth of 1 mm. Changes in thenar tissue perfusion were not detectable. Conclusion Vasopressin causes a deterioration of oral mucosal blood flow but not in thenar tissue perfusion. 

Introduction Sepsis alters vascular reactivity. We studied the impact of peritonitis and endotoxemia on hepatic and superior mesenteric arterial contractility.
section_name: Introduction

section_content: We studied fecal peritonitis (P, n = 7), endotoxin-infusion (E, n = 8) and control (C, n = 6) for 24 hours after abdominal surgery and eight control pigs without surgery (SPA). Systemic and regional hemodynamics and ex-vivo splanchnic vascular reactivity to norepinephrine (NE; tissue bath) were measured and cumulative dose-response curves to NE were constructed. Tension was expressed in grams. 

Results CO increased (P < 0. 05) in P and E. SMA flow (median (range)) decreased in C from 24 (15-30) to 15 (11-21) ml/kg/min (P = 0. 022) (Table 1 ).
section_name: Materials and methods

section_content: N of arterial rings SMA (g) HA (g)
section_name: Table 1 (abstract P36)

section_content: Mean arterial pressure (MAP) during continuous and intermittent bolus infusion of terlipressin in endotexemic ewes. 

Introduction Tissue Doppler imaging (TDI) is a novel technique that measures myocardial velocity. The peak early diastolic mitral annulus velocity (E′) offers a relatively preload-insensitive measure of LV relaxation. There are scant data regarding its use in sepsis or endotoxemia. This study sought to determine the effect of endotoxemia upon TDI variables. Methods With ethics committee approval, 10 male Sprague-Dawley rats were studied. Anesthesia was induced with alfaxalone and maintained with isofluorane. Mechanical ventilation was performed via tracheostomy. All rats received 0. 9% NaCl 3 ml/hour via a carotid line. Immediately after baseline assessment (T = 0), rats received 1 ml/kg i. v. infusion over 30 minutes (study group (n = 5), endotoxin 10 mg/ml (Escherichia coli O55:B5; Sigma, MO, USA); control group, 0. 9% NaCl). Echocardiography was performed (15 MHz transducer, Vivid5; GE Healthcare) at T = 0, 60 minutes (T = 60) and 2. 5 hours (T = 150). Measurements included the heart rate, mean arterial pressure (MAP), femoral venous pressure, LV outflow tract diameter and flow (peak velocity (V peak ), cardiac output (CO)), peak early diastolic mitral inflow (E), peak systolic mitral annulus velocity (S′) and E′. 

Results There was no significant difference in mean ± SD weight (study 539 ± 88 g, control 504 ± 108 g, P = 0. 6) or hemodynamic variables at T = 0. At T = 60, only V peak was higher in the study group compared with controls (1. 29 ± 0. 24 vs 0. 86 ± 0. 21 m/s, P = 0. 03). The study group demonstrated lower MAP, E and E′ at T = 150 (Table 1 ). Methods Fifteen patients with myocardial depression related to septic shock were enrolled. All patients had SIRS criteria, culture isolation of one or more pathogens, positive procalcitonin, SBP < 90 mmHg unresponsive to load challenge. We defined myocardial depression as a reduced SvO 2 in the presence of increased brain natriuretic peptide secretion and Troponin I release, and systolic and/or diastolic dysfunction by transoesophageal echo evaluation of ejection fraction and mitral annulus tissue Doppler imaging velocities. All patients received levosimendan infusion for 24 hours at 0. 1 µg/kg/min combined with norepinephrine. Results Data were obtained by evaluating the average of the percentage variation between T 0 (starting infusion) and T 1 (24 hours after infusion), T 2 (48 hours), T 3 (72 hours), T 4 (96 hours), T 5 (120 hours) and T 6 (144 hours). Levosimendan significantly increased SvO 2 and ejection fraction, and decreased

Troponin I and brain natriuretic peptide. Levosimendan improved diastolic function by increasing the E′ velocity at tissue Doppler imaging at 48 hours. All data were analysed by the Fisher F test. Introduction Sickeuthroid syndrome is very frequent in critically ill patients. Cytokines may have a role in this syndrome. IL-12 is involved in the central regulation of the hypothalamic-pituitarythyroid (HPT) axis during illness. The aim of this study is to evaluate the relationship of IL-12 and thyroid functions in septic patients. Materials and methods Twenty-four septic patients and 18 healthy controls were enrolled into the study with the mean ages of 49. 9 ± 20. 6 and 45. 8 ± 22. 3 years, respectively. Hyperthyroid and hypothyroid patients were excluded. Free triiodothyronine (fT3), free thyroxine (fT4) and TSH were measured simultaneously with IL-12.
section_name: Figure 1 (abstract P35)

section_content: The mean IL-12, fT3, fT4 and TSH values of septic patients and the control group are presented in Table 1. IL-12 was significantly higher in septic patients (19. 05 ± 10. 7 pg/ml vs 4. 8 ± 2. 0 pg/ml, P < 0. 005). fT3 and TSH values were significantly low in septic patients. There was a significantly strong correlation between IL-12 and fT4 in septic patients but not fT3 and TSH (r = 0. 88, P = 000). There was no correlation between IL-12 and other thyroid indices in the control group. Introduction We show the effect of a network system in the treatment of pediatric septic shock, especially for children with Waterhouse-Friderichsen syndrome. In 2003 we founded a pediatric intensive care network with 15 children's hospitals in Lower Saxony, Germany. The aims were the standardisation of clinical therapies, implementation of training programs and the installation of an emergency system in the region of lower Saxony. Methods The first standard was implemented for the treatment of the Waterhouse-Friderichsen syndrome. At first, we started with the educational program. The program included different central symposia about septic shock in children. The second step was the standardisation of the diagnosis and the therapy, including the administration of human protein C concentrate (PC), and the clinical pathways. We implemented a round-the-clock emergency system with the possibility for transportation of critically ill patients, permanent consultation of the tertiary medical center and onsite treatment through the tertiary center staff if the patient could not be transferred. All patients were announced to the tertiary medical S17 center directly after admission into the network hospitals. The final step was the presentation of the project in the different hospitals.
section_name: Results

section_content: We treated 10 children with Waterhouse-Friderichsen syndrome in the network. Three of them were attended on site and seven were transferred in the tertiary center. The announcement time in eight cases was 15 minutes-1 hour. Primarily, a consultation was accomplishing routinely. The transportation team of the tertiary center continued the treatment on site and afterwards in the center. All patients showed typical signs of Waterhouse-Friderichsen syndrome with purpura fulminans and severe multiorgan failure. No patient died and only one patient had necrosis of the skin, which existed already at admission. The others had a restitution ad integrum. No adverse effects were observed with the PC concentrate administration. Conclusions The network system and the standard treatment with PC worked without severe problems. The survival rate and the outcome in our small study group were excellent. Our experience allows us to enlarge the system on other diseases. 

Introduction Neonates and infants in the ICU are at high risk of severe infections and sepsis. Often it is not easy to diagnose sepsis based only on clinical findings; reliable biomarkers are needed to prove the diagnosis. 

Objective To study the value of procalcitonin (PCT) as a marker, verifying the diagnosis, which enables the start of de-escalating ABT in patients with clinical signs of sepsis. Methods Three hundred and seventy-four patients on artificial lung ventilation from two pediatric ICUs of two Russian hospitals were enrolled. Blood samples for PCT testing (PCT LIA; BRAHMS AG, Germany) were taken under suspicion of sepsis or exacerbation of bacterial infection. In the first stage (January-December 2005), 50 neonates (age 6 (4-12) days) with various perinatal pathologies were studied (Group A), and routine ABT was prescribed, with blood samples taken and stored for further PCT assessment. In the second stage (January-November 2006), 324 infants (age 6 (1. 5-9. 4) months) after cardiac surgery were enrolled (Group B), and ABT was adjusted based on PCT-testing results. PCT > 2 ng/ml indicative of systemic bacterial inflammation in addition to clinical signs of sepsis was an indication for ABT with carbapenems. Data are shown as the median and interquartile range. 

Results Group A. Sepsis was diagnosed in 16/50 (32%) patients. PCT > 2 ng/ml was observed in 23/50 (46%) cases, including 15/16 (94%) patients with clinically diagnosed sepsis. In patients with PCT > 2 ng/ml the mortality rate was 7. 7% if carbapenems (meropenem or imipenem/cilastatin) were administered (n = 13), compared with 20% with different ABT (n = 10) -although in patients with PCT < 2 ng/ml (n = 27), ABT with carbapenems (n = 12) resulted in paradoxically higher mortality compared with other ABT schemes (n = 15): 17% vs 6. 6%. Group B. Sepsis was defined in 24/324 (7. 4%) patients. PCT > 2 ng/ml was in 53/324 (16%) cases, including all patients with clinically diagnosed sepsis. 

Early ABT with meropenem, combined with vancomycin or linezolid, allowed one to decrease sepsis-related mortality in these patients to 29%, which used to be as high as 74% before the introduction of this algorithm (P = 0. 0028). Conclusion Early verification of sepsis using PCT combined with carbapenems-based ABT enables decreasing sepsis-related mortality in critically ill infants and newborns staying in the ICU. 

Available online http://ccforum. com/supplements/11/S2 Introduction The aim of this study was to investigate the prevalence of endotoxemia early after elective surgical procedures in patients admitted to an ICU of a university hospital. Methods One hundred and four nonselect patients were recruited. Patients were excluded if they were admitted during the weekend or from another ICU and if they were on chronic dialysis. Within 4 hours of admission functional data were collected and severity scores (APACHE, SOFA) calculated. Arterial blood samples were also taken and processed according to Spectral Diagnostics' endotoxin activity (EA) assay [1]. The method allows one to express EA as a function of each patient's neutrophil chemiluminescence activity (on a scale from 0 to 1). An EA level of 0. 4 is approximately equivalent to an endotoxin concentration of 25-50 pg/ml, and a level of 0. 6 is approximately equivalent to a LPS concentration of 100-200 pg/ml. Data were analysed according to EA ranges: low (EA < 0. 4), intermediate (0. 4 ≤ EA < 0. 6), and high (EA ≥ 0. 6). Differences between ranges of EA were assessed by analysis of variance (Sigma Stat, SPSS), accepting P < 0. 05 as significant. Data are expressed as the mean ± SD.
section_name: Results

section_content: In our case mix, patients were 68 (65%) in the low group, 17 (17%) in the intermediate group and 19 (18%) in the high group. Age (61 ± 17 years) was not significantly different in the three groups (P = 0. 493). Functional and severity scores were not significantly different between groups. Average values were as follows: WBC 11,093 ± 4605 n/mm 3 (P = 0. 385), HR 76 ± 16 bpm (P = 0. 898), MAP 88. 8 ± 13. 6 mmHg (P = 0. 576), lactate 1. 18 ± 0. 77 mmol/l (P = 0. 370), PaO 2 /FiO 2 383 ± 109 mmHg (P = 0. 474), APACHE II score 8. 3 ± 3. 7 (P = 0. 542) and SOFA score 1. 5 ± 1. 4 (P = 0. 245). Interestingly, those patients with higher levels of EA were characterized by longer length of stay in the ICU. The ICU length of stay was 1. 9 ± 3. Objectives To evaluate in septic patients the plasma levels of sTREM-1, a soluble form of TREM-1, which seems to play an important role in inflammatory diseases, and to determine whether plasma sTREM-1 could be used as a diagnostic and prognostic marker in sepsis in the surgical ICU. Design An observational clinical study. Setting The surgical ICU of the University Hospital of Heidelberg, Germany. 

Patients Patients admitted to the ICU over a 6-month period with clinical evidence of severe sepsis or septic shock. Interventions None.
section_name: Results

section_content: Sixty-six intensive care patients were enrolled in the study within the first 24 hours after the onset of severe sepsis or septic shock. Twenty-one healthy individuals served as controls. At day 0, day 1 and day 3 after diagnosis of severe sepsis or septic shock, plasma sTREM-1 was measured by ELISA. Plasma sTREM-1 concentrations of healthy controls did not differ from patients with severe sepsis or septic shock at day 0 (42. 8 ± 44. 9 pg/ml vs 40. 8 ± 45. 5 pg/ml, not significant), day 1 (42. 8 ± 44. 9 pg/ml vs 48. 6 ± 57. 2 pg/ml, not significant) nor at day 3 (42. 8 ± 44. 9 pg/ml vs 51. 9 ± 52. 8 pg/ml, not significant). Survivors were defined as patients surviving to at least day 28. There were no differences of plasma sTREM-1 between survivors and nonsurvivors at day 0, day 1 and day 3 (34. 8 ± 44 52. 4 pg/ml vs 49. 5 ± 35. 9 pg/ml, 42. 6 ± 61. 1 pg/ml vs 59. 6 ± 47. 1 pg/ml, and 47. 9 ± 60. 2 pg/ml vs 58. 2 ± 37. 1 pg/ml, not significant).
section_name: Measurements and results

section_content: In this study including surgical patients with severe sepsis or septic shock, plasma sTREM-1 is not elevated compared with healthy controls. Furthermore, the measurement of plasma sTREM-1 did not allow one to differ between survivors and nonsurvivors. The suggested role of sTREM-1 as a diagnostic and prognostic marker in sepsis was not confirmed in this study.
section_name: Conclusion

section_content: Can plasma-free DNA concentration be a diagnostic tool in critically ill septic patients?

B Orbey 1, H Cuhruk 1, M Tulunay 1, M Oral 2, N Unal 1, H Ozdag 3 1 Ankara University Medical Faculty, Anesthesiology and ICM, Ankara, Turkey; 2 AÜTF, Anesthesiology and ICU, Ankara, Turkey; 3 Ankara University, Biotechnology Institute, Ankara, Turkey Critical Care 2007, 11(Suppl 2):P48 (doi: 10. 1186/cc5208)

Recent evidence suggests that the plasma-free DNA concentration has potential use as a prognostic marker in many clinical situations including sepsis, trauma, and acute stroke [1]. However, its predictive value is arguable. We hypothesized that plasma DNA is increased in septic patients admitted to the ICU compared with nonseptic ICU patients, and it is correlated with disease severity and clinical outcome. Forty-two consecutive patients (11 septic, 31 nonseptic) admitted to a mixed ICU and mechanically ventilated were recruited. Plasmafree DNA concentration was measured by real-time PCR assay for the β-globin gene, and the APACHE II score, SOFA score, serum C-reactive protein (CRP) concentrations, procalcitonin (PCT) concentrations, serum lipid concentrations, and clinical outcome (ICU/hospital days and mortality) were assessed on admission to the ICU. Assessments and samplings were repeated as the diagnosis of the patients changed (sepsis, severe sepsis and septic shock). Finally, 86 plasma samples were collected. Descriptive statistics, Mann-Whitney U, Kruskall-Wallis and Spearman's tests, and receiver operating characteristic analysis were used when appropriate. Demographic data were similar. ICU and hospital mortalities were 26. 2% and 33. 3%, respectively. The mean DNA concentrations on admission were significantly higher in ICU patients compared with healthy subjects (n = 11) (13,405 GE/ml versus 390 GE/ml, P < 0. 05) and septic patients compared with nonseptic patients (33,170 GE/ml versus 1,171 GE/ml, P < 0. 001). Furthermore, during the overall ICU stay, increased DNA concentration associated with the increase of severity of illness was noted; however, this increase was statistically significant only between septic and septic shock samples (26,624 GE/ml versus 42,861 GE/ml, P < 0. 05). The area under the curve obtained for the plasma-free DNA concentration in distinguishing between septic and nonseptic patients on admission was 0. 9 (sensitivity 84%, specificity, 95%; cutoff 4,083 GE/ml). Also, the plasma-free DNA concentration was found to be higher in patients who died in the ICU compared with patients who survived, although not statistically significant. The DNA concentration demonstrated a significant correlation with CRP (P = 0. 037, r = 0. 365), PCT (P = 0. 007, r = 0. 457) and highdensity lipoprotein (P = 0. 015, r = -0. 415) concentrations. 

In conclusion, plasma DNA may be a potentially valuable tool to confirm the diagnosis of sepsis on admission to the ICU and to monitor disease severity.
section_name: P48

section_content: Greater than the sum of its parts: C-reactive protein and the calculated ion gap together are superior in predicting mortality in critically ill surgical patients Introduction Inadequate tissue perfusion and an uncontrolled systemic inflammatory response are associated with poor outcome in critically ill surgical patients. An increased concentration of unmeasured anions, reflecting hypoperfusion, and the magnitude of the early inflammatory response both correlate strongly with mortality. Our aim was to assess the relationship between these factors, and their ability in combination to predict outcome. Methods In a prospective study we evaluated 108 consecutive patients admitted to a surgical high dependency unit. Regional Ethics Committee approval was obtained. Serum electrolytes, albumin, phosphate, lactate and C-reactive protein (CRP) were measured on admission and on day 1. We derived the calculated ion gap (CIG) using a simplified modification of the Stewart-Figge equations. 

Results Based on previous work, thresholds of 10 mmol/l for CIG and 100 mg/l for CRP were used to categorise patients. Of the patients with a CRP < 100 mg/l, 15. 4% had an elevated CIG. Of the patients with a CRP > 100 mg/l, 36. 7% had an elevated CIG (P = 0. 016, chi-square test). Patients (n = 63) with a CIG < 10 mmol/l and CRP < 100 mg/l had a 1. 5% mortality, whereas those (n = 11) with a CIG > 10 mmol/l and CRP > 100 mg/l had a 54. 5% mortality (P < 0. 0001, chi-square test) (Table 1 ).
section_name: P49

section_content: Inflammation is a potent cause of oxidative stress, which in turn results in endothelial damage and increased concentrations of unmeasured anions. The combination of CRP and the CIG, as markers of inflammation and inadequate tissue perfusion, respectively, is a powerful predictor of mortality in the critically ill surgical patient.
section_name: Conclusion

section_content: Introduction C-reactive protein (CRP) is a non-specific marker that may be used to assess the magnitude of the inflammatory response in critically ill surgical patients. Our aim was to determine the temporal relationship between CRP measurement and mortality. Methods In a prospective study conducted in a surgical highdependency unit (HDU), 132 consecutive patients were evaluated. Regional Ethics Committee approval was obtained. Serum CRP was measured on admission, day 1 and day 2 and was evaluated with respect to inhospital mortality. Results CRP on admission to HDU discriminated survivors from nonsurvivors (P < 0. 0001, analysis of variance). A CRP greater than 100 mg/l correlated very strongly with mortality. The mortality in patients with a CRP less than 100 mg/l (n = 93) was 2. 2%. The mortality in patients with a CRP greater than 100 mg/l (n = 39) was 25. 6% (P < 0. 0001, chi-square test), (Table 1 ). However, there were no significant differences in CRP with respect to mortality on day 1 or day 2 (P = 0. 136 and 0. 236, respectively). Conclusion CRP on admission to the surgical HDU is a powerful predictor of mortality (P < 0. 0001), but this correlation does not persist after the initial measurement. Our data suggest that early CRP measurement should be undertaken in all critically ill surgical patients in order to quantify the ultimate magnitude of the inflammatory response and the associated mortality. Introduction We tested the ability of the biphasic aPTT waveform to diagnosis sepsis in patients presenting to the Emergency Department (ED) with the systemic inflammatory response syndrome (SIRS). The biphasic aPTT waveform (BPW), which results from rapid complexing of VLDL and C-reactive protein during aPTT testing, has demonstrated promise as an early diagnostic test for sepsis. Methods A prospective, observational study was designed in which all patients presenting to the ED of an urban university hospital were screened for SIRS. Patients with SIRS unrelated to trauma or myocardial infarction were eligible. Plasma for BPW testing was obtained at the time of enrollment and daily for 7 days in admitted subjects. The primary outcome was a diagnosis of sepsis related to the presence of a BPW at enrollment. Secondary measures were mortality related to the BPW, correlation of any positive BPW with sepsis, and of the BPW with statin therapy. Two criteria for a positive test, light transmittance at 18 seconds (TL18) and the initial slope of the waveform (slope) are used. Two independent experts made the final diagnosis. Results We screened 5,400 consecutive admissions to the ED, identified 207 eligible subjects and enrolled 105 participants. The BPW was present at enrollment in 12 subjects by TL18 and in 28 subjects by slope. Forty-six out of 105 subjects eventually developed a BPW, 54 were diagnosed with sepsis. The sensitivity and specificity for sepsis were 17% (95% CI, 7-27. 6) and 93. 8% (95% CI, 87-100) by TL18 and 26. 9% (95% CI, 14. 9-38. 9) and 71. 4% (95% CI, 58. 7-84. 1) by slope. The positive predictive value of the test was 75 by TL18 and 50 by slope criteria. The AUC for ROC analysis of the BPW for diagnosis of sepsis is 0. 469 by TL18 and 0. 560 by slope. The odds ratio for developing sepsis related to any positive BPW was 2. 977. The odds ratio for development of a BPW in patients on a statin at the time of presentation was 0. 597. Five subjects died by 28 days, 4/5 having a BPW.
section_name: P50 C-reactive protein predicts mortality on admission to a surgical high-dependency unit

section_content: The BPW has no utility in the ED to predict the development of sepsis in at-risk patients. The development of a BPW at any time during the hospital stay correlates with an increased risk of sepsis and mortality. Baseline statin therapy may reduce the chance of developing a BPW.
section_name: Conclusion

section_content: Functional protein C levels in septic patients E Lafuente, I Pratima, M Fernandes, J Gomes da Silva, F Moura, F Santos, I Guimaraes, R Lopes, P Santos Padre Americo, Penafiel, Portugal Critical Care 2007, 11(Suppl 2):P52 (doi: 10. 1186/cc5212) Objective To know whether functional protein C (FPC) levels in critical septic patients could be intended as an evolution marker correlated with prognosis and mortality. Materials and methods A prospective study with determination of FPC levels in all septic patients admitted to the ICU. We used the IL test™ PC kit (Instrumentation Laboratory; synthetic chromogenic substrate). We considered an abnormal low FPC when levels were below 40%, normal FPC when levels were above 80% and low FPC when levels where between 40% and 80%. Data included patient age, diagnosis, SAPS II, SOFA score, OSF and mortality. The analytical data included serum lactate and FPC. Patients were divided into three groups: group I (FPC below 40%), group II (FPC 40-80%) and group III (FPC above 80%). The statistical study was performed with the Analyse-it ® program. The severity was defined by the usual criteria of SAPS II score and lactate levels and then compared with the different FPC groups. Mortality was considered.
section_name: P52

section_content: We included 65 patients. The total mortality rate was 16. 9% (11 patients).
section_name: Results

section_content: We found a direct and a progressive relation with statistical significance between the higher mortality rate and the lower protein C values. The results could mean that the level of protein C can be used as an evolution marker in septic patients. 

Introduction We sought to determine whether severe protein C (PC) deficiency was associated with organ dysfunction (OD) and mortality in adult patients with severe sepsis. Methods Retrospective examination of Lilly trials in adult patients with severe sepsis in which PC measurements were obtained at baseline. Severe PC deficiency was defined as ≤ 40% of normal. The Student t test was used to compare mean APACHE II and OD differences, while the chi-squared or Fisher's exact test was used for mortality. 

Introduction Human protein C (PC) concentrate may anticipate thrombotic microangiopathy and facilitate fibrinolysis in the severe hemolytic uremic syndrome (HUS). We report the effects of PC in six HUS patients. HUS is characterized by a simultaneous occurrence of hemolytic anemia, thrombocytopenia and acute renal failure. Postdiarrheal HUS is often based on an infection with EHEC producing Shiga toxins. Our current pathogenetic understanding is that Shiga toxins cause endothelial injury, leading to thrombotic microangiopathy. There is still a 5% rate of mortality particularly caused by cerebral involvement. Methods We treated six children with a severe cerebral manifestation, five of them suffered from a multiple organ dysfunction syndrome (MODS), of HUS with PC over 7-10 days. All patients suffered peritoneal dialysis, one patient a plasmapheresis. In addition to the treatment of the MODS, all of them received 100-200 U/day PC. Results All of the patients showed signs of disseminated intravascular coagulation. We found typical hypodense lesions in basal ganglia and edema of the brain in CT. During the therapy with PC, MODS was remarkable improved and abnormal D-dimer and PAI-1 levels could be normalised. All of the patients recovered a nearly normal kidney function. Two patients persisted in a severe reduced neurological status. The others showed only slight or no neurological disabilities on discharge. No adverse effects were observed with the PC concentrate administration. Conclusions There is no generally accepted therapy regimen to treat HUS in case of neurological involvement. Mortality in HUS accompanied with cerebral microangiopathy is high and difficult to alter. This is the first trial of human PC concentrate administration to anticipate thrombotic microangiopathy in HUS. All of our patients showed rapid clinical improvement under PC administration. Four of six patients were discharged in a healthy condition despite their severe disease. The containment of the severe neurological involvement and the lack of side effects in the treatment with human PC concentrate administration in our patients yield hope that PC treatment may be an effective therapy regimen in the treatment of severe HUS.
section_name: Conclusions

section_content: A Donati, M Romanelli, L Romagnoli, M Ruzzi, V Beato, V Gabbanelli, S Nataloni, T Principi, P Pelaia AOU Umberto I Ancona, Rianimazione Clinica, Ancona, Italy Critical Care 2007, 11(Suppl 2):P55 (doi: 10. 1186/cc5215)

In severe sepsis, microcirculatory dysfunction caused by inflammation, endothelial activation and procoagulant response leads to mithocondrial dysfunction (termed microcirculatory and mitochondrial distress syndrome). If undetected, this condition can lead to parenchymal cellular distress and so to organ failure. As regional and microcirculatory distress are independent of systemic hemodynamic-derived and oxygen-derived variables, we recorded the course of microvascular parameters with a Microscan Video Microscope (Microvision, The Netherlands) in four patients with severe sepsis. We studied the sublingual region because of its embryologic correlation to splanchnic circulation, its thin mucosa. The instrument used a new improved imaging modality for observation of the microcirculation called sidestream dark-field imaging. We consider here four patients with severe sepsis related to esophagectomy, severe polytrauma with splanchnic organ damage and mediastinitis treated with drotrecogin alpha (activated) (DA) at 24 µg/kg/hour for 96 hours. The patients were admitted to the ICU, ventilated mechanically, monitored hemodynamically via a PICCO system and supported with dobutamine. Videomicroscopy was made before administration of DA and was repeated every 24 hours during the treatment with DA and at 24 hours after its suspension. We recorded values of blood pressure, cardiac function, lactate levels, acid-base balance, temperature and dobutamine dosage. At admission the sublingual microcirculation showed a low capillary density, vessel heterogeneity with a qualitative low flow and flow-no flow. After the first 24 hours from the beginning of DA infusion, sublingual flow showed an increase of vessel density, particularly of the number of small vessels, and the number of continuously perfused vessels increased during and post therapy with DA. We analyzed the microvascular flow with a simple semiquantitative method dividing the images into four equal quadrants and quantificating flow (hyperdynamic, continuous, sluggish, flow-no flow, no flow) for each cohort of vessel diameter (small, medium, large). We analyzed the mean value of results of three images for each patient pre and post DA therapy. Data are presented as the median. Before starting therapy with DA, the microvascular flow index (MFI) was 2. 06 for small vessels, 2. 09 for medium vessels, and 2. 37 for large vessels. After DA infusion, the MFI was 3, 3, and 3, respectively, for small, medium and large

Available online http://ccforum. com/supplements/11/S2 vessels. Differences between groups were assessed using the Mann-Whitney U test. We showed a statistically significant difference with P < 0. 0001 between MFI before and post DA therapy. We demonstrated a quantitative and qualitative improvement of sublingual microcirculation with an increase of capillary density distribution (area-width) and average velocity versus vessel width. The course of microvascular blood flow may play an important role in sepsis and septic shock because of its relation to the development of multiple organ failure and death. Several studies have demonstrated that changes in microvascular perfusion are an independent predictor of outcome. The improvement of the microcirculation and vascular tone in septic shock by DA is probably related to its anticoagulant/antithrombotic and antiinflammatory action, to the decrease of TNFα production and inhibition of iNOS induction, and to improvement of endothelial barrier function and inhibition of chemotaxis, but further investigations are required to elucidate the exact mechanisms. These observations could suggest that DA could have a particular interest in the early management of severe sepsis.
section_name: P55 Increasing microcirculation after drotrecogin alfa (activated)

section_content: Multicentre audit of the use of drotrecogin alfa (activated) in UK critical care units Background Following positive results from PROWESS, drotrecogin alfa (activated) (DrotAA) was approved for use in Europe in August 2002. At this time, ICNARC commenced an audit to monitor the diffusion of the drug into routine UK practice and to undertake a nonrandomised evaluation of its effectiveness. Methods A data collection form was developed and tested to mirror the information collected in PROWESS. This form was completed for every admission that received DrotAA and a senior clinician confirmed completeness. Data were entered centrally and validated. Analysis Admissions receiving DrotAA and with severe sepsis and two or more organ dysfunctions in the first 24 hours following admission to the unit were matched to controls on: source of admission; organ dysfunctions; ICNARC physiology score; and age. Four pools of control patients were used for matching: (a) historic admissions (January 2000-August 2002) from the same unit; (b) contemporaneous admissions from the same unit; (c) contemporaneous admissions from units that never used DrotAA; and (d) contemporaneous admissions from units prior to their first use of DrotAA. Analyses were undertaken using conditional, fixedeffects, Poisson regression. 

Results One hundred and twelve units participated in the audit; 1,079 admissions (one in 16) with severe sepsis and two or more organ dysfunctions in the first 24 hours following admission to the unit received DrotAA. For the four control pools, matching was successful for: (a) 657 (61%); (b) 820 (76%); (c) 702 (65%); and (d) 965 (89%). Matched cases were older, more acutely ill and had higher hospital mortality than unmatched cases. The relative risks (95% confidence interval) associated with DrotAA were: (a) 0. 84 (0. 77-0. 92); (b) 0. 85 (0. 78-0. 93); (c) 0. 75 (0. 68-0. 83); and (d) 0. 80 (0. 73-0. 86). A priori subgroup analyses indicated greater effect for patients with three or more organ dysfunctions. Interpretation All results were consistent with PROWESS, but need to be interpreted with caution due to their nonrandomised nature and the potential existence of important unknown confounders. In addition, the fact that only one in 16 potentially suitable admissions received DrotAA suggests a strong possibility for treatment bias. Discussion During 4 years of treatment of severe sepsis in the ICU with APC, important changes were observed: faster recognition and diagnosis, transfer to the reference hospital, and introduction of adequate therapy. The decrease in the surviving ratio in 2006 is probably due to a more serious state of the admitted patients -more initial infection located in the abdomen after surgery.
section_name: P56

section_name: P57

section_content: The education program is essential in increasing the number of fast recognitions, which influences the surviving ratio.
section_name: Conclusion

section_content: Introduction As one of the few treatment interventions to demonstrate mortality efficacy at a randomized controlled trial level [1], the prescription of drotrecogin alfa-activated (DrotAA) (Xigris™), where appropriate, plays an important role in the management of severe sepsis. However, concerns regarding the potential for serious bleeding events have helped sustain a degree of scepticism regarding the use of DrotAA [2]. As early adopters of evidence-based medicine, Cardiff Critical Care Unit has prescribed DrotAA since late 2002 and has considerable experience with S23 respect to its use. The aim of this study was to demonstrate the safety profile and efficacy of DrotAA treatment within a large, 29bed university hospital critical care unit. Methods Demographic data were obtained from the unit's daily updated Riyadh ICU programme database and clinical data were collected from patients' medical notes and observation charts. All data were prospectively entered into our DrotAA registry, the results of which are shown below. 

Results Between October 2002 and November 2005, 133 patients with severe sepsis were treated with DrotAA. The mean age was 61 years (range: 20-87 years) and 54% were male. The mean admission APACHE II score was 22 (range: 11-48), and on day 1 of DrotAA infusion the median number of organs that failed was 2. 0 (range: 0-4), 129/133 (97%) were mechanically ventilated and 131/133 (98. 5%) were on vasopressors. The median time to start DrotAA after documented diagnosis of severe sepsis was 12. 6 hours (range: 0-41 hours) and the median duration of DrotAA infusion was 89. 5 hours (range: 10-105 hours). The incidence of serious (life-threatening) bleeding events was 2. 3% (n = 3): gastrointestinal (n = 1), intraabdominal (n = 1) and intrathoracic (n = 1); all were nonfatal and there were no intracranial bleeds. The 28-day mortality was 31. 6%, the ICU mortality was 33. 1%, the hospital mortality was 36. 8% and the 1-year mortality was 47%. Conclusions This is one of the largest UK registries of DrotAA usage published to date. Our results demonstrate a very low incidence of serious bleeding events associated with DrotAA treatment (2. 3% vs 3. 5% in PROWESS); it is interesting to note that all three adverse events occurred prior to 2004. This detail, combined with our low median time to start DrotAA infusion (which has steadily decreased over the past 4 years), would suggest the presence of a learning curve for DrotAA usage on ICUs. It is also encouraging to note that our overall hospital mortality was lower than the predicted APACHE II hospital mortality for these patients (36. 8% vs 42. 4%). Finally, this is one of the first UK studies to describe long-term mortality outcome in patients receiving DrotAA therapy. Further studies are required to more formally assess the impact of DrotAA treatment on long-term survival from severe sepsis. References 1. Bernard Introduction Activated protein C (APC) is an endogenous protein, which has fibrinolytic and anti-inflammatory properties. This is available as human recombinant APC and is used in the treatment of patients with severe sepsis [1]. The National Institute of Clinical Excellence (NICE) suggested guidelines for the use of APC [2]. We retrospectively audited the records of patients who received APC during their admission to our ICU between January 2003 and August 2006. We audited our practice against three parameters: compliance with the NICE guidelines, accuracy of data forms, and outcomes of treatment.
section_name: P58 A large, single-centre UK registry of drotrecogin alfa-activated use

section_content: From January 2003 to August 2006 we used APC to treat 44 severely septic patients in our ICU. We obtained complete data for 37 patients. We collected data from the case notes, ICU charts and drotrecogin alfa (activated) data forms and recorded relevant data on an Excel spreadsheet proforma. 

Results NICE guidelines. We were 100% compliant with patient selection criteria for APC administration, which included a known or suspected site of infection, SIRS criteria and organ dysfunction criteria. All prescriptions were made by intensive care consultants. We were not fully compliant in excluding patients who met exclusion criteria (2/37 patients), although these cases were justified clinically by the consultants prior to administration. Data entry. In 90% of cases the patient selection fields were completed, but only 30% of the exclusion and outcome fields were completed. In 30% of patients where a lactate ≥1. 5 times normal was listed as one of the inclusion criteria, it was not associated with a pH ≤ 7. 30 or a base deficit ≥5. 0; however, all these patients had ≥3 organ-dysfunction criteria and hence still met the inclusion criteria. 

Outcomes. Seven patients (15. 9%) died during or within 28 days of APC administration. The standardised mortality ratio (SMR) was lower in patients receiving APC when compared with the rest of patients admitted over the same period (SMR ~0. 5 vs ~1. 0). Twenty-eight patients had an APACHE II score <25 and the effective cost per survivor was ~€16,800. Patients with APACHE II scores ≥25 had an effective cost per survivor of ~€22,400. Nine patients (20. 5%) had their drotrecogin alfa (activated) infusions interrupted or discontinued for various reasons (including seven patients who had hemorrhagic complications, three of which were serious).
section_name: Materials and methods

section_content: We use APC in compliance with the NICE guidelines. APC is cost-effective in patients with an APACHE II score <25 in our ICU. 

Introduction Grand River Hospital (GRH) is a 495-bed nonteaching, acute care referral center in Southwestern Ontario, supporting regional programs including dialysis, oncology, surgery and stroke thrombolysis. Since the introduction of drotrecogin alfa (activated) (DAA) in 2003, GRH has treated 58 patients with this agent for severe sepsis and septic shock. We sought to compare, where possible, GRH ICU/hospital outcomes and bleeding complications with those from published literature. Methods All charts for patients treated with DAA in our CAICU for severe sepsis and septic shock between February 2003 and June 2006 were reviewed retrospectively for infection source, ICU/ hospital mortality, survival by age and incidence of hemorrhagic complications. Where possible, we compare our data with those from PROWESS, ENHANCE and a recent Ontario/Quebec-based multicenter usage evaluation. A two-organ system failure threshold for DAA consideration is used. Outcomes were categorized as ICU mortality and hospital mortality, as opposed to 28-day mortality used in PROWESS and ENHANCE. 

Results All 58 patients who received DAA at GRH were included in our analysis. The mean age of patients treated with DAA was
section_name: Conclusions and recommendations

section_content: To establish whether activated protein C (APC) is safe in surgical patients with intra-abdominal sepsis (IAS). APC has been used in the treatment of IAS in our hospital since 2003. Fears persist regarding the potential for clinically significant bleeding in this surgical subgroup of patients. Methods Forty-four patients with IAS received APC as a standardized regime between March 2003 and August 2006. A retrospective medical and ICU chart review was undertaken. Data collected included clinically significant bleeding episodes and mortality. Descriptive subgroup analysis of unexpected nonsurvivors(died in the ICU with APACHE II (APII) predicted mortality < 50%) and unexpected survivors (survived to ICU discharge with APII predicted mortality > 50%) was performed as statistical analysis of such small patient numbers was inappropriate. Results There was one episode of clinically significant bleeding (from a mucous fistula: self-limiting). There were no intracranial haemorrhagic events. ICU mortality was 38. 6% with mean APII predicted mortality of 37. 16% and inhospital mortality of 47. 7%. These exceeded rates for APC-treated surgical cohorts in the literature [1]. Unexpected survivors (5/44) were more likely to have been admitted from theatre. They had a shorter mean time from hospital-ICU admission (10. 5 vs 5. 6 days), duration on a ventilator (10. 8 vs 17. 5 days), vasopressor (9 vs 17. 7 days) and renal replacement therapy (10. 5 vs 23. 5 days) dependence. All unexpected nonsurvivors (11/44) had a diagnosis of fistula or perforation. They were more likely to have been transferred to the ICU from another hospital or ward than from theatre. Comorbidities were more severe. Results A total of 444 patients were admitted to the ICU with the diagnosis of sepsis or severe sepsis. One hundred and forty-nine severe septic patients were assessed for APC: 85 patients received APC, and 64 patients could not receive APC due to financial problems or due to bleeding, coagulation derangement or very recent surgeries. In the total 444 septic patients admitted to the ICU, 152 patients expired (mortality 34. 2%) and 141 had positive blood culture; 233 patients received inotrops. The total average APACHE II score was 28. 9 and for expired patients was 35. 1. 

Out of the total 444 septic patients 149 were assessed for APC; in the 85 patients fulfilling criteria for and receiving APC the mortality was 43. 5%, and for the 64 patients not receiving APC the mortality was 64%. All suspected septic patients admitted to the ICU received appropriate antibiotic therapy within 4 hours of ICU admission and were upgraded/changed according to culture/ sensitivity reports if necessary. In the nonreceiving group (i. e. 64 patients) 12 patients could not receive APC due to financial restriction because initially foreigners were not entitled to this drug in Bahrain, but later this restriction was removed, and the remaining 52 patients could not receive either due to bleeding or very recent surgeries. Some patients could not receive complete treatment either due to bleeding complications or because they died. The mortality was measured at 28 days. Furthermore, as per our experience, if APC started in the early stage of sepsis and the course is completed the outcome is better -out of 85 patients who received APC, 45 patients received in the early stage and completed the dose and 32 of these patients survived at 28-day mortality. An average three (ventilator-free) organs failed in the survival group and two (ventilator-free) organs failed in the expired group. Seventeen patients started treatment in the early stage and could not complete the course due to bleeding or other complications, 11 patients expired; 13 patients started in the late stage and completed the course, five patients expiring; and 10 patients started in the late stage and eight of these patients expired.
section_name: Introduction and objective

section_content: On the basis of our experience and the results of multiple trials, we recommend APC should be given to the patients who meet all the inclusion criteria.
section_name: Conclusion

section_content: Drotrecogin alfa in patients with severe sepsis: experience from a tertiary care center in North India Introduction Drotrecogin alfa (DA) remains the only approved drug for the specific treatment of severe sepsis. Although it has been in wide clinical usage, there are no data on its use in Indian patients. 

Methods Fifty-seven patients with severe sepsis (age 51 ± 15 years, range 20-77 years, male:female 32:25) admitted to the ICU were included. All patients had three or more signs of systemic inflammation with at least two major organ dysfunctions or the presence of ARDS. Demographic, clinical and laboratory profiles at baseline, and during the hospital stay, development of complications, duration of hospital/ICU stay and hospital survival were recorded. All management decisions including initiation of DA (24 µ/kg/hour), duration of treatment as well as its discontinuation were the prerogative of the ICU team.
section_name: P63

section_content: The majority of patients had a confirmed infection (n = 36, 63. 2%), with the commonest site of focus being the lung (n = 25, 43. 9%) followed by the abdomen (n = 13, 22. 8%). A significant number of patients had at least three major organ dysfunctions (n = 37, 64. 9%). A large number of patients had an APACHE II score in the range 25-29 (n = 22, 38. 6%). Whereas 44 patients (77. 2%) were on some kind of vasopressor support, 51 needed ventilatory support (89. 5%). A total of 20 patients (35. 1%) survived to hospital discharge. Patients received DA for a mean duration of 74. 8 ± 26. 2 hours (range 25-96 hours) and only 32 patients could complete treatment (56. 1%). The outcome was significantly better in patients who could complete therapy (53. 1% vs 13. 6%, P = 0. 001). Major bleeding necessitating discontinuation was seen in four patients (7%) whereas the other 21 patients (36. 9%) died before completing 96 hours of therapy. DA was initiated within 48 hours of development of organ dysfunction in the majority of patients (n = 31, 54. 4%), and a trend towards better outcome in patients with early treatment was noted although the difference did not reach statistical significance (mortality rate 58% for early treatment vs 73. 1% for delayed treatment, P = not significant). Conclusion Mortality of patients with severe sepsis remains high despite the introduction of DA. Early institution may be associated with better outcomes. Patients receiving a complete course of treatment have better survival.
section_name: Results

section_content: Severe sepsis and drotrecogin alfa (activated) use: results from the PROGRESS registry Introduction Since the launch of drotrecogin alfa (activated) (DAA) a number of institutions and countries have published data on its use in clinical practice, based on audit or registry data. Such publications have tended to report DAA use in higher disease severity populations together with higher mortality outcomes compared with clinical trials. We utilized the Global PROGRESS (Promoting Global Research Excellence in Severe Sepsis) database to examine the baseline characteristics and outcome of patients with and without DAA treatment. Methods PROGRESS is a global, noninterventional, multicenter, prospective, observational study of severe sepsis patients treated in ICUs. Patients must have had a diagnosis of severe sepsis and have been treated in an ICU at a participating institution. All treatment modalities were as per standard of care at the participating institutions. We analyzed baseline characteristics and hospital mortality. We also performed an adjusted mortality analysis for DAA patients due to baseline imbalances in patients with and without DAA therapy.
section_name: P64

section_content: Overall, 12,492 patients with severe sepsis from 37 countries were enrolled and 882 (7%) patients received DAA therapy. The highest rate of use of DAA was seen in the United States at 27% (206/760). Patients who received DAA versus those who did not receive DAA were younger (median age 59 versus 64 years), had greater organ dysfunction (cardiovascular dysfunction (90% versus 74%), respiratory dysfunction (90% versus 81%), renal dysfunction (60% versus 45%), metabolic abnormalities (63% versus 42%), three or more organ dysfunctions (84% versus 67%)) and higher median APACHE II scores (25. 0 vs 23. 0), all P < 0. 001. The mortality rate for patients treated with DAA was 49. 6% and for those not treated with DAA was 49. 7%. Although imbalances in other baseline characteristics, not collected in PROGRESS, may have also been present, when adjusted for age and number of organ dysfunctions the odds ratio for hospital mortality associated with DAA use was 0. 75 (0. 63-0. 90, P = 0. 002).
section_name: Results

section_content: In a large global registry, patients receiving DAA therapy were younger with higher disease severity than patients not treated with DAA. When adjusted for age and number of organ dysfunctions, DAA was associated with a reduction in the odds of hospital mortality similar to that seen at day 28 in PROWESS. These data are supportive of the effectiveness of DAA in clinical practice. 

Introduction A multicentre, prospective, observational study was conducted in 12 intensive therapy units (ITUs) in India from June 2006 to November 2006 to determine the incidence and outcome of severe sepsis among adult patients. Methods All patients admitted to ITUs were screened daily for SIRS, organ dysfunction and severe sepsis. Patients with severe sepsis were further studied. 

Results A total of 1,344 ITU admissions were studied. There were no SIRS in 31. 3% and SIRS without organ dysfunction in 51. 6%. SIRS with organ dysfunction was found in 230 (17. 1%) patients, of which 54 (23. 5%) were not due to sepsis and 176 (76. 5%) were due to sepsis. The incidence of severe sepsis was 13. 1% of all admissions. The mean age of the study population was 54. 9 years (SD 17. 6), of which 67% were male. The median APACHE II score was 22 (IQR 17-28) with predominant (88%) medical admission. ITU mortality of all admissions was 13. 9% and that of Available online http://ccforum. com/supplements/11/S2
section_name: Conclusion

section_content: severe sepsis was 54. 1%. Hospital mortality and 28-day mortality of severe sepsis were 59. 3% and 57. 6%, respectively. The standardized mortality ratio of severe sepsis patients was 1. 40. 

The median duration of stay in ITUs of the severe sepsis cohort who survived was 6 days (IQR [3] [4] [5] [6] [7] [8] [9] [10] [11] [12]. The number of episodes where infection was the primary reason for admission to the ITU was 89. 8% and the rest of episodes were ITU acquired. See Figure 1 for infection characteristics. Conclusion Sepsis was common in Indian ITUs and had predominant medical populations. ITU mortality was higher compared with western literature. Gram-positive infections were less common although the incidence of parasitic and viral infections were higher than in the West. 

Introduction Sepsis occurs in 16. 6% of the patients in the Brazilian ICU and is associated with a high mortality rate (46. 6%). Several studies show different pathogenic agents among countries and increased antibiotic resistance. This study aims to describe the pathogen profile in Brazil's ICU septic patients. Methods A prospective cohort study involving 75 ICUs all over Brazil was performed. All patients who were admitted or developed sepsis during a 1-month period were enrolled and followed until the 28th day and/or until their discharge. 

Results A total of 521 patients filled the criteria of sepsis and were studied. The two main sources of infection were pneumonia and the abdominal tract. Gram-negative bacteria were isolated in 40. 1%, followed by Gram-positive (38. 8%) and fungus (5% S27 unit (NCCU) is at the moment unknown. It is known that being a patient in the intensive care environment is in itself a risk factor for the development of bacteraemia (3. 2-4. 1 per 100 admissions in several papers). The higher amount of invasive procedures and the severity of illness in this group of patients have been blamed. The aims of our study are: (1) to identify the incidence of bacteraemia in the NCCU, (2) to recognise the incidence of bloodstream infection (SIRS with bacteraemia), (3) to identify the most common pathogens associated with bacteraemia, and (4) to promote the continuous collection of data aiming to follow the behaviour of this problem in time. Methods This is a prospective observational study looking at the presence of positive blood cultures in all the patients admitted to the NCCU during the period from 1 June to 31 August 2006. Blood cultures were taken from a peripheral site under aseptic conditions as per the NCCU guidelines. We tried to identify how many of the patients with positive blood cultures had evidence of concomitant SIRS/sepsis, as described by the modified Bone criteria, and the severity of this. An attempt was made to identify the most frequent microorganisms involved in this problem as well as their antibiotic susceptibility. As a secondary aim of our study we described the number of fatalities in the patients with bacteraemia. We tried to focus our approach to the fact that we serve a large neurological/surgical population as well as general patients and to see whether we could pinpoint differences in these two groups. Results There were 201 patients admitted to the unit during the period of our study; 140 of these were neurosciences (NS) patients and the rest (61) were general (G) (either medical or surgical). Most of the patients were men and had a mean APACHE II score of 39 (NS group 33, G group 45). There were in total 64 episodes of positive blood cultures (BC); 39 of these episodes were accompanied by inflammatory signs (incidence of bloodstream infections of 19. 4% of total admissions). Twenty-five of the episodes were not associated to clinical signs of infection. There were more patients with at least one episode of positive BC in the NS group (29 (20. 7%)) than in the G group (10 (16. 39%)). Out of 49 episodes in the NS group, 59. 18% (29) were associated to some degree of inflammatory response (SIRS, severe sepsis, and MODS). Out of 15 episodes in the G group, 66. 6% (10) developed inflammatory response. In 59% (25) of the positive BCs, the organism isolated was coagulase-negative staphylococcus (CNS). In the G group, 47% (7) grew CNS, 33% were diverse Gram-negatives and in 20% other Gram-positives. In the NS group, 64% (31) of isolates grew CNS, 21% were other Grampositives and 15% were Gram-negatives. In 47 (73. 4%) episodes of positive BC, the patients had either a central venous catheter or an arterial catheter. In 36 (56. 2%) of the episodes the patients were already on antibiotics at the time of the sampling. The most frequent agent isolated was coagulase-negative Staphylococcus aureus, in 39 (59%) of the cases. 

From the patients that had at least one positive BC, nine died; seven (78%) patients were in the G group, and two (22%) in the NS group. Twenty-five (68%) patients with at least one episode of positive BC had a systemic inflammatory response at the time of sampling. Seven (28%) of these died during the first 30 days in the NCCU. Nine (23%) patients had severe sepsis and four (44%) of these died. Four (10. 2%) patients had MODS and three (75%) of these died.
section_name: Figure 1 (abstract P65)

section_content: We had an incidence of positive blood cultures of almost 32% of the total admissions; 19. 4% of admissions developed bloodstream infections. These numbers are very high if we consider the published data. Due to the specialist origin of our unit, we had more cases in the neurosciences group than in the general group. However, the incidence of sepsis and MOF in these patients was almost the same for both groups. We noted, as well, a larger number of deaths in the patients with sepsis and MOF. There needs to be more studies aiming to establish a casual relationship to explain this. CNS was the most frequently isolated organism and there was no difference among the groups. There is a potential for increased mortality in the patients that develop bloodstream infections in our unit, and we need to implement urgent measures to decrease them while further research is done in this area. We determined the rate of compliance and the prognostic value of the RB, the MB and of each bundle element.
section_name: Conclusions

section_content: We analyzed 135 consecutive episodes of septic shock. 

The main sources of infection were: abdomen 39. 5%, lung 29. 9%, and urinary tract infection 11. 1%. Global hospital mortality was 44. 4%. Nonsurvivors were older (71 vs 64 years; P = 0. 01), and had a higher APACHE II score (25 vs 20; P = 0. 000), a higher SOFA score (10 vs 9; P = 0. 001) and a higher number or organ dysfunctions at sepsis presentation (4 vs 3; P = 0. 007). The rate of compliance with the RB was 38%. There were significant differences in mortality between compliant (C) and noncompliant (NC) groups despite the similar characteristics and the severity of septic shock. The NC group had a 58% mortality rate and the C group 22% (RR 2. 6 (95% CI 1. 49-4. 5, P = 0. 001)). The number needed to treat to save one life was 3. The compliance rate with MB was only 20%, and there were no differences in mortality between the C and NC groups (57. 9% vs 52. 6%). We only found differences in mortality between the C and NC groups in four bundle elements: serum lactate measured before 6 hours (35. 2% vs 65. 4%; P = 0. 007), early broad-spectrum antibiotics (36.
section_name: Results

section_content: extent to which units comply with the surviving sepsis guidelines as promulgated by the International Sepsis Forum [1]. Method Following appropriate institutional approval, 43 ICUs were selected using the proportional probability sampling technique. This was applied to a national database of ICUs. Every seventh bed was selected from all the serially placed units. Data collected included the presence of an infection control policy (including guidelines for performance of blood cultures), recording of culture results, microbiological support structures, glucose control protocols and protocols for sedation analgesia and muscle relaxation. 

Results Forty-three out of a total of 458 units were sampled. The mean age of patients was 55 years with a male:female ratio of 60:40. Sixty-eight per cent of patients were admitted post surgery. 

An infection control policy was present in 77% of units. A practice procedure for blood culture sampling was used in 51% of units, with records of culture results being documented in 56% of units. Microbiologists were available in 65% of units and they were involved in ward rounds in 26% of units. Physical consultation by a microbiologist in 47% of units and telephone consultations in 54% of units were possible. Sixty-one per cent of units had a glucose control policy. Sedation, analgesia and neuromuscular blockade protocols were present in 33%, 26% and 21% of units, respectively. See Table 1. Participants were given the patient history, and completed the rest of their assessment using the HPS and Intellivue patient monitoring. Data were collected to compare the use of bedside monitor displays with and without horizon screen trends in the care of patients with sepsis. Group 1 (n = 37) completed the sepsis scenario using a standard screen display, and group 2 (n = 38) had the addition of horizon trends on the display.
section_name: S29

section_content: The point that marked the onset of sepsis was when each of the physiologic parameters met the current evidence-based screening criteria (HR > 90, RR > 20, MAP < 65, temperature >38°C). Results of this study found statistically significant differences between the standard screen and horizons screen participant groups in the speed in which clinicians were able to reach each measured outcome. This was true in each of the five outcome measurements: onset of sepsis (P < 0. 001), initiation of fluid bolus (P < 0. 001), initiation of vasopressor (P < 0. 001), blood culture order (P = 0. 012), and antibiotic administration (P = 0. 020). Conclusions These results support the hypothesis that monitoring using horizons trending does indeed contribute to faster clinical decision-making in the simulated septic patient experience. Future research should concentrate on replicating these results in a real clinical environment. Background Direct microbiological input to critical care is essential for the management of the septic patient. Early broadspectrum antimicrobial therapy with appropriate diagnostic studies to ascertain causative organisms is well established; there should be reassessment with the aim of using narrow-spectrum antibiotics to prevent the development of antimicrobial resistance, to reduce toxicity and to reduce costs [1]. In systematic analysis of ward rounds in ICUs the information most commonly missing from a patient's file concerned microbiology findings [2]. Methods We performed a telephone survey of all NHS critical care units in the North West of England (n = 31). Each unit was telephoned and the duty consultant was asked a series of questions relating to the type of microbiology input to their critical care unit.
section_name: Results

section_name: P75 Medical microbiology ward rounds in critical care

section_content: We achieved a 100% response rate. The study looked at 11 teaching hospitals and 21 district general hospitals representing 12% of UK ICUs: 26 (83%) critical care units had live computerised access to microbiology data, 21 (68%) units had an antibiotic policy in place, and 19 (61%) units had a formal microbiology ward round. With the frequency ranging from once per week (one unit) to 7 days per week (four units), most units with a microbiology ward round had this service Monday-Friday (12 units). When asked to rate the value of this ward round, the mean score was 8. 6 out of a possible 10 (range 10-5, mode 9). In those units without a microbiology ward round the desirability of such a service was scored on average at 8. 5 out of 10 (range 10-3, mode 9).
section_name: Results

section_content: Direct microbiological advice at the bedside is highly valued by ICU consultants. Antibiotic prescribing is generally well controlled, with two-thirds of units having an agreed antibiotic policy in place. Work will continue to determine whether these results reflect the national picture in the United Kingdom.
section_name: Conclusion

section_content: Selective digestive decontamination (SDD) can reduce the incidence of ventilatory-associated pneumonia (VAP). Some concerns have been raised about the risk of selection of resistant bacteria. We evaluated the impact of a SDD regimen on the incidence of VAP and the development of resistant pathogens. Methods In a polyvalent eight-bed ICU, a retrospective analysis was performed of two periods of 8 months before (no-SDD, 178 patients, mean SAPS II 44. 8) and after (SDD, 110 patients, mean SAPS II 48. 9) the use of SDD with amphotericin, tobramycin and colistin for oropharyngeal and gastric decontamination and mupirocin for nasal decontamination. The results were analyzed with the chi-square test.
section_name: Introduction

section_content: The incidence of VAP was reduced in the SDD group, even though it was not statistically significant (26. 9% vs 16. 3%, P = 0. 138). The mortality of VAP and septic shock was reduced respectively from 39. 6% to 16. 7% (P = 0. 312) and from 60% to 37. 5% (P = 0. 835). During the SDD period, Gram-positive infections increased while Gram-negative infections and Candida infections showed a reduction. The percentage of resistant species showed a reduction from 49. 1% to 30. 5% in all the categories of pathogens (Table 1 ). ). The incidence of bloodstream-related infection (BSI) related to all types of CVC is between 2. 9 and 11. 3 per 1,000 catheter-days [1]. In CT or cardiology practice the incidence for all CVC-related infection is 2. 9-4. 5 per 1,000 catheter-days. The incidence of BSI is reduced using tunnelled CVC, although there are little published data on the incidence of BSI in tunnelled CVC in CT critical care. CVCrelated infection has been recognised as a priority in the UK initiative 'Saving Lives' [2]. We reviewed tunnelled CVC-related infection in a tertiary UK CT centre with a significant transplant population. 

Methods A retrospective analysis from November 2001 to 2006 of culture and sensitivity results of tunnelled CVC tips (Bard Groshong ® cuffed catheter and HemoGlide ® ) and blood cultures from the same patients. 

Results Ninety-three CT critical care patients received a tunnelled subclavian CVC. The indications were inotropes (n = 40 (43%)), antibiotic administration (n = 27 (29%)), RRT (n = 14 (15. 1%)) and unknown (n = 10 (10. 8%)). The mean duration of the catheter remaining in situ was 36 days (SD 44. 0, range 1-164). Culture results are presented in Table 1. Twelve patients had an established CVC-related BSI. The mean infection rate/1,000 catheter-days was 3. 6. Background Nosocomial catheter-related bloodstream infections (CR-BSI) have been associated with increased morbidity and possibly increased mortality in critically ill patients. Central venous catheters impregnated with rifampin and minocycline (RM) have been shown to decrease rates of colonization and CR-BSI when compared with controls and with the chlorhexidine/silver sulfadiazine catheter. However, recent randomized trials challenged the clinical impact of such catheters, showing decreased rates in colonization but not in CR-BSI. We designed this pilot trial to compare the rates of colonization and CR-BSI in RM catheters and controls in a Brazilian population of critically ill patients. Methods A prospective, nonrandomized, controlled clinical trial was conducted in one medico-surgical 19-bed ICU. Adult patients needing a double or triple central venous catheter were sequentially assigned in permuted blocks of five to undergo insertion of a control or RM-impregnated catheter. After removal, all tips were cultured by the roll-plate method in association with one or two peripheral blood cultures. Rates of colonization and CR-BSI were recorded and compared. Results Of 120 catheters inserted, 100 could be evaluated for colonization and CR-BSI. Forty-nine in the uncoated group and 51 in the coated group. Clinical characteristics of patients and risk for infection were similar in the two groups, use of propofol was more frequent in the uncoated group and the presence of a vascular device, other than the study catheter, was more frequent in the antibiotic-coated group. Three RM-coated catheters (5. 9%) were colonized compared with nine (18. 4%) control catheters (relative risk, 0,28; 95% confidence interval, 0. 07-1. 096; P = 0. 05). Three cases of CR-BSI (5. 9%) occurred in patients who received RM catheters compared with five in the control group (10. 2%). There was no significant differences in the incidence of CR-BSI between RM-coated and uncoated catheters. Uncoated catheters were more frequently colonized but this difference just failed to show statistical significance. When the duration of catheter placement were taken into consideration, Kaplan-Meier analysis showed no significant differences in the risk of colonization or CR-BSI between RM-coated and uncoated catheters. Rates of CR-BSI were seven per 1,000 catheter-days in the RM-coated group compared with 11. 4 per 1,000 catheter-days in the uncoated group (P = 0. 7). Gram-positive and Gram-negative organisms were similarly responsible for colonizing catheters in our study; there was no difference in rates of colonization by Candida species.
section_name: Results

section_content: In this pilot study, we showed a trend toward lower rates of colonization in RM-coated catheters when compared with uncoated control catheters. The incidence and rates of CR-BSI were similar in the two groups, probably because of a small number of catheters studied. Development of a prospective randomized trial with a larger number of patients is underway to confirm or refute these results. 

Introduction Blood culture was commonly performed, without any specific indication, at the Emergency Department. However, the true positive rate was found to be very low (1. 8-5%) and patients with true bacteremia usually had such risk factors as an indwelling catheter, severe underlying disease or an immunocompromised state. This study was performed to determine the usefulness of performing blood culture for managing febrile immunocompetent patients who present to the Emergency Department. Method We prospectively analyzed the medical characteristic and the results of blood culture of febrile immunocompetent patients who were more than 18 years old and who presented to the Chonnam National University Hospital Emergency Center from April 2005 to October 2005. Fever was defined as a single axillary temperature higher than 38. 0°C. The two sets of blood for culture were drawn at the antecubital area by the emergency physician who knew well how to obtain blood for culture. The bacteremia was classified as true bacteremia or contamination, based on the presence of clinical signs and symptoms and also on the criteria of MacGregor. For the true bacteremia group, we further investigated the changes that occurred with the previously administered antibiotic therapy according to the results of blood culture. Results This study included 182 patients: of the 182 cultures, only 36 were positive with 10 contaminants (5. 5%) and 26 true positives (14. 3%). The most common disease that required blood culture in the Emergency Department was respiratory infection (57/182) and the most common disease with true bacteremia was urinary infection (41. 9%). A low initial level of albumin was the characteristic associated with a positive blood culture result on multivariate analysis. Management of only five patients was influenced by the blood culture results (2. 7%).
section_name: Conclusion

section_content: The blood cultures, as were usually ordered for febrile immunocompetent patients in the Emergency Department, rarely altered patient management and the results had limited usefulness. The emergency physician who initially treats these patients has to consider this limitation of blood culture. Also, eliminating blood cultures for immunocompetent patients may hold down unnecessary medical expenses. Introduction Despite improvements in technology and healthcare services, mortality rates from severe sepsis have remained unchanged over the past few decades. Exciting new data are emerging about the benefits of early, aggressive management in the Emergency Room (ER). We carried out this study to study the patterns of antibiotic administration in our ER and their effects on the length of hospitalization and survival. Methods This was a prospective, observational cohort study that reviewed all adult patients presenting with systemic inflammatory response syndrome (SIRS) to the ER of the Aga Khan University Hospital, which is a 554-bed primary care/tertiary care referral facility, over a period from February to June 2006. SIRS was defined according to the criteria proscribed by the Society of Critical Care Medicine. A research officer stationed in the ER identified patients. Exclusion criteria were age < 18 years, patients transferred from other hospitals or chronic care facilities. Demographic and study-specific data were collected. The patient was followed until subsequent death or discharge. The primary outcome variable was survival to hospital discharge and the secondary outcome was length of hospitalization. An independent t-test analysis was carried out for the primary independent variable (timing of administration of antibiotics) and primary outcome (mortality) for significant differences between the groups. A twosided P value <0. 05 was considered as statistical significance. Logistic regression modeling was used to examine survival as a function of timing of antibiotic administration. Results Patients enrolled in the study numbered 111. At presentation 36 patients (32. 4%) had 1/4 criteria for SIRS, 67 (60. 4%) had 2/4 criteria and only eight (7. 2%) patients had 3/4 criteria. Sixteen patients (14. 4%) were in shock. Sepsis was confirmed by cultures in 96 (86. 5%) patients. One hundred (90. 1%) patients received intravenous antibiotics in the ER; the average time from triage to actual administration was 2. 8 (± 1. 86) hours. The timing of administration of antibiotics was statistically significant in determining survival. Patients with sepsis and receiving antibiotics in <1 hour had a mean survival of 99% and a length of hospitalization of 3 days as compared with those receiving antibiotics in 1-4 hours (84. 5% survival, LOS 5. 25 days) and patients who received antibiotics in >4 hours (76% survival, LOS 7 days, P < 0. 003). Using a Cox regression model, we were able to demonstrate that survival dropped acutely with an hourly delay in antibiotic administration. Overall mortality with sepsis was 34. 2%. Conclusions Administration of appropriate antibiotics within 4 hours of arrival in the ER has a significantly favorable impact on survival in patients with sepsis.
section_name: Conclusion

section_name: P83

section_name: P84

section_content: An open, before and after, single-center trial, in the medical ICU of the University Hospital of Besancon, France. A first period (A, retrospective) extended during 18 months (April 2003-October 2004) without antibiotic prophylaxis and was followed by a second period (B, prospective) during 18 months (November 2004 -April 2006). Patients received prophylaxis treatment by amoxicillin and clavulanic acid, shortly after intubation and during a 24-hour period. Inclusion criteria were medical loss of consciousness, Glasgow Coma Score < 8, and length of intubation > 48 hours. Results A total of 101 patients were enrolled, 61 patients during period A and 40 patients during period B. No significant differences were found between mean age (48. 6 years vs 50. 4 years old), SAP II score (44. 5 vs 46. 5), aetiology of coma (mainly ischaemic stroke, cardiac arrest, refractory epilepsy, intoxication), and early-onset (n = 12 vs n = 6) or late-onset pneumonia (n = 1 vs n = 2). During period B, the time for onset of colonisation (6. 6 days vs 3 days, P = 0. 008) or pneumonia (8. 4 days vs 4. 2 days, P = 0. 03) was increased compared with period A. We did not diagnose multidrug-resistant infection or colonisation. No difference was found with regard to mortality and morbidity: duration of mechanical ventilation (5. 7 days vs 6. 7 days) or total hospitalisation stay (26. 6 days vs 16. 9 days), total mortality (n = 9 vs n = 10 patients) or at day 28 (n = 6 vs n = 7 patients), respectively, in periods A and B. In multivariate analysis, tobacco, cardiac arrest and ischaemic stroke were independent risk factors of pneumonia. Conclusion In our study, contrary to previous ones [1, 2], antibioprophylaxy did not show a decrease in the incidence of nosocomial pneumonia in medical comatose patients with Glasgow Coma Score < 8 under mechanical ventilation. On the other hand, antibiotics induce a later onset of colonisation and lung infections. Despite a prevention of early-onset nosocomial pneumonia, our data do not support the use of regular prophylactic antibiotics. This was applied to a national database of ICUs. Every seventh bed was selected from all the serially placed units. Antibiotic therapy was reviewed by two independent reviewers. Data collected included the appropriateness of pretherapy cultures, postculture modification of therapy, duration of therapy and, finally, impact of appropriate antibiotic choice on mortality. 

Results See Table 1. Public-sector practice is better with respect to pretherapy sampling and duration of treatment. Better modification of treatment occurs in the private sector. Overall mortality of both groups was 10/82 (12%) when antibiotic choice was appropriate compared with 28/90 (31%) (P < 0. 05) when therapy was inappropriate.
section_name: Patients and methods

section_content: The medical literature shows that the most important prognosis factor in nosocomial pneumonia is the correct empirical antimicrobial therapy. Recently the microorganisms have been becoming more resistant to the usual antibiotics and there are many reports of Gram-negative bacilli (GNB) only susceptible to Polimixyn b (PB). The ATS guideline does not suggest the use of PB as an empirical therapy, while the Brazilian Sepsis Guideline (BG) allows the use of this antibiotic in special circumstances. The aim of this study was to compare the efficacy of both guidelines, based on the microbiological data. Methods This is a retrospective study with 93 cases of nosocomial pneumonia diagnosed according to the ATS criteria, managed in our ICU from 1 February 2005 to 16 September 2006. We analyzed the efficacy of both guidelines, using them during all the study period or stratifying the patients into two groups according to the research median period (24 November 2005). Results There were 67 cases of ventilator-associated pneumonia (VAP) and 26 cases of non-VAP. The overall result shows that the ATS would be effective in 76% (CI 67-85%) and the BG in 87. 9% (CI 81-94. 7%) of the cases. This difference was statistically significant (P = 0. 035). The most prevalent bacteria were Acinetobacter sp. and Pseudomonas aeruginosa. From February to August 2005 there were a burden of multiresistant (MR) GNB, only susceptible to PB. Using the ATS or the BG in this period, the guidelines would be effective in 64% (CI 51-77%) and 84. 4% (CI 74. 8-94%) respectively (P = 0. 017). In the second half of the study we controlled the MR GNB, and the efficacy of both guidelines were similar between ATS and BG (97% vs 93. 9%; P = 1). Conclusions Our data show that the more restrictive ATS guideline can significantly lead to a wrong empirical therapy in MR GNB high-prevalence situations. The use of the BG can lead to a better empirical treatment in this situation. This information enhances the need for ICU flora knowledge, which are seasonal, so there is no 'all time and place perfect guideline', although the BG was a better option in our ICU than the ATS guideline. 

Available online http://ccforum. com/supplements/11/S2
section_name: Introduction

section_content: Cytokines play an important role in pulmonary host defense. However, nonuniform findings have been reported about the correlation between bronchoalveolar bacterial burden and the lung inflammatory response. Objective The aim of the present study was to evaluate the relationship between bronchoalveolar cytokine expression and bacterial burden in mechanically ventilated patients with suspected pneumonia. Methods Mechanically ventilated patients with suspected pneumonia admitted to the ICU from November 2004 to January 2006 were prospectively enrolled. Fiberoptic bronchoalveolar lavage (BAL) was performed with 150 ml sterile isotonic saline in three aliquots of 50 ml; local anesthetic was not used. BAL samples for microbiologic quantitative cultures and BAL cytokines -IL-6, IL 8, TNFα, granulocyte colony-stimulating factor (G-CSF) and granulocyte-monocyte colony-stimulating factor (GM-CSF)were measured. Results Fifty-nine patients were included, and most of the patients (79. 7%) had prior antibiotic therapy. Twenty-two patients (37. 2%) had a positive bacterial culture defined as a diagnostic threshold >10,000 colony-forming units/ml. Only the concentration of TNFα was significantly higher in the group of patients with positive BAL (Table 1 ). Conclusions (1) There is a significant correlation between TNFα in BAL fluid and the lung bacterial burden. (2) BAL TNFα is an early marker of pneumonia in mechanical ventilated patients despite prior antibiotic therapy. Clinical implication Cytokine measurements in BAL may be a diagnostic tool to support the diagnosis of the initial phase of pneumonia.
section_name: Introduction

section_content: Introduction Delays in adequate antibiotic therapy for ventilatorassociated pneumonia (VAP) are associated with poor outcomes, and early use of broad-spectrum antibiotics may improve clinical outcomes. However, indiscriminant use of broad-spectrum antibiotics is associated with the emergence of antibiotic-resistant bacteria, fungal infections, and increased healthcare costs. The purpose of this study was to determine optimal empiric treatment of VAP by comparing a strategy of combination therapy to monotherapy with broad-spectrum antibiotics. Methods In a multicenter trial, we randomized mechanically ventilated adult patients with suspected VAP that developed after 96 hours in the ICU to receive either meropenem and ciprofloxacin or meropenem alone, as initial therapy. In addition, before starting antibiotics, diagnostic specimens were obtained using either bronchoalveolar lavage with quantitative cultures or standard endotracheal aspirates.
section_name: P95 A randomized trial of combination therapy versus monotherapy for the empiric treatment of suspected ventilator-associated pneumonia

section_content: We randomized 740 patients in 28 ICUs in Canada and the United States. The baseline characteristics and etiologies of VAP were similar between groups. There was no difference in 28day mortality between the combination and monotherapy groups (RR = 1. 05, 95% confidence interval 0. 78-1. 42; P = 0. 74). The duration of ICU and hospital stay, clinical and microbiological response to treatment, emergence of antibiotic-resistant bacteria, isolation of Clostridium difficile, and fungal colonization were similar between groups. Combination therapy resulted in a higher rate of adequate empiric therapy compared with monotherapy (93. 1% vs 85. 3%, P = 0. 01). In a subgroup of patients with infection due to pseudomonas species, acinetobacter species and multidrug-resistant Gram-negative bacilli at enrollment (n = 56), the adequacy of initial antibiotics was 82. 4% in the combination group versus 18. 8% in the monotherapy group (P < 0. 001); this difference was associated with an increase in the microbiological eradication of the infecting organisms (64. 1% vs 29. 4%, P = 0. 05) but no differences in clinical outcomes.
section_name: Results

section_content: In patients who have suspected VAP, empiric treatment with combination therapy, as compared with monotherapy, is safe and is associated with a higher rate of adequate antimicrobial coverage but has no effect on clinical outcomes. 

Introduction This prospective pilot study set out to develop an animal model of Pseudomonas aeruginosa that would be suitable for the application of molecular techniques to evaluate virulence in which instillation of a reference strain of P. aeruginosa results in a monoculture ventilator-associated pneumonia. For this purpose, male adult greyhounds were used in an animal research laboratory. Methods The animals were anaesthetised, orally intubated and mechanically ventilated. An inoculum of P. aeruginosa (strain PA01) was instilled into the oropharynx at 1 hour and 8 hours postintubation. The animals were terminated at 78 hours.
section_name: Conclusion

section_content: Pneumonia was evaluated based on macroscopic grading and microbiological (bacterial count) findings. We were able to maintain anaesthetic, haemodynamic and respiratory support for the study duration of 78 hours. A monobacterial pulmonary infection was established in four out of five animals. Administration of ceftriaxone 1 g daily effectively suppressed all other bacteria. This allowed proliferation of the single strain P. aeruginosa (PA01) we had inoculated with no culture of other organisms. Conclusions Over a short period of time we were able to reproduce a monoculture ventilator-associated pneumonia in a significant percentage of animals. We successfully developed an animal ICU model that we were able to sustain for 78 hours. This canine model of P. aeruginosa (PA01) ventilator-associated pneumonia is suitable for the application of molecular techniques such as signature-tagged mutagenesis, differential fluorescence induction, and in vivo expression technology.
section_name: Results

section_name: P97

section_content: The mean number of i. v. antibiotics at the end of the study (mean 7 days) were two times greater with placebo than with twice-daily AMK (P < 0. 02) (Figure 1 ). For daily and twice-daily AMK, the serum C max were 1. 3 and 1. 8 µg/ml (respectively) on day 1, and 2. 3 and 3. 2 µg/ml on day 3. Mean trough levels were 0. 87 and 1. 49 µg/ml. Tracheal aspirate levels (mean) on day 3 were 6. 9 mg/ml (daily) and 16. 2 mg/ml (twice daily). Aerosol AMK was well tolerated with no difference in adverse events across treatment groups. Conclusion Repeated doses of adjunctive inhaled AMK to mechanically ventilated patients with Gram-negative pneumonia was safe, well tolerated, and associated with less i. v. antibiotic use than placebo.
section_name: Results

section_content: Acinetobacter baumanii infection in a surgical intensive care unit Methods All patients were managed within the liver ICU and received standard care. Laboratory data were collected daily and entered onto a specialist database. MDRA-positive cultures from blood, bronchoalveolar lavage, drain fluid or samples taken at laparotomy in the context of systemic inflammatory response syndrome resulted in the initiation of tigecycline 100 mg i. v. followed by 50 mg i. v. 12 hourly.
section_name: P98 Management of an outbreak of multiresistant

section_content: Eleven patients received tigecycline treatment for MDRA infections (seven male). Ten patients had a single course whilst one patient had three courses. Underlying disease states were necrotising pancreatitis (one), polytrauma (one), post hepatectomy (one), acute and acute on chronic liver failure (four), and postorthotopic liver transplant (four). The median duration of treatment was 9 days (range 4-23 days); courses <7 days were because of patient death (2/11). The mean APACHE II score at initiation of therapy was 18 (range 13-26). Four out of 11 survived to ICU discharge and 3/11 to hospital discharge. Tigecycline was well tolerated but increases in corrected calcium were observed in 9/11 patients. The patient that received three courses of treatment had elevations in corrected calcium after each course. For the 11 patients, the mean corrected calcium before treatment with tigecycline was 2. 41 mmol/l. The mean corrected calcium on finishing the course increased to 2. 59 mmol/l (P = 0. 012). There was no correlation between duration of treatment with tigecycline and degree of change in the corrected calcium level (r = 0. 08). Hypercalcaemia resolved on discontinuation of the drug; 7/11 survived >7 days after treatment and had a mean corrected calcium of 2. 46 mmol/l, which was not significantly different from pretreatment levels (P = 0. 94). Conclusion Tigecycline is well tolerated but appears to be associated with an elevated corrected calcium in critically ill patients. This returns to baseline values on discontinuation of the drug.
section_name: Results

section_content: A Spooner
section_name: P101 A pharmacokinetic basis for improving therapeutic outcomes of aminoglycoside therapy during continuous venovenous haemodiafiltration

section_content: In vitro experiments included static and dynamic evaluations of resin binding. Whole human blood was stimulated with endotoxin for 4 hours at 37°C; or with the addition of added cytokines or toxins for evaluation. For static conditions, 4 ml plasma with 1 ml resin were incubated for up to 10 hours. Aliquots were withdrawn between 0 and 10 hours and cytokine inflammatory mediator and toxin adsorption were determined with standard ELISAs, multianalyte protein arrays, HPLC and diode array adsorption spectroscopy. Dynamic conditions involved defining the optimal linear velocity and evaluating the adsorption capacity under flow conditions. These experiments used a closed circuit consisting of a plasma filter and resin cartridge. Samples were taken from a blood port and immediately before and after the plasma cartridge. In addition, serum, pre-cartridge and postcartridge plasma samples were also taken from septic patients undergoing CPFA. 

Results Endotoxin-stimulated blood or samples from septic patients had high levels of cytokines and inflammatory mediators. The resin used in the CPFA adsorptive cartridge showed higher than 80% adsorption under both static and dynamic conditions for: IL-1α, IL-6, IL-8, MIP-1α and MIP-1β, TNFα, MCP, myoglobin. IL-6 appeared to be particularly adsorbed by the cartridge. Severe septic patients had great variability and often very high levels of IL-6 ranging from normal levels (50 pg/ml) up to 12,300 pg/ml. The mean of 10 patients treated before CPFA was 1,775 ± 3757 pg/ml, while postsession IL-6 was 995 ± 2178 pg/ml. The plasma levels before the cartridge ranged from 12 pg/ml to 1,750 pg/ml, while postcartridge levels were below the level of detection. Results Levels of AEA did not change after PMX-DHP in the either the BP constant group or the BP elevation group, whereas levels of 2-AG decreased significantly after PMX-DHP in the BP elevation group but not in the BP constant group (Figure 1 ). F2-isoprostane gradually increased after PMX-DHP. On the other hand, levels of F2isoprostane remained constant in the BP elevation group (Figure 2 ). Objective The aim of the study was to investigate the effectiveness of octreotide at different doses in reducing the hypoglycemic attacks and the need for dextrose in treatment of refractory and recurrence hypoglycemia related to the toxicity of sulfonylurea. Methods In the study, 40 New Zealand type of rabbits were used weighing between 2,500 and 3,000 g. The rabbits were randomly divided into four groups consisting of 10 animals. All the animals were given gliclazide 100 mg orally. For the treatment of hypoglycemic attacks in Group I, only 15 cm 3 50% dextrose (7. 5 g) intravenously (i. v. ) was used; in Group II, Group III and Group IV octreotide 25 µg, 50 µg and 100 µg single doses were used subcutaneously, respectively. Octreotide was given in Groups II and III and Group IV at the eighth hour (when hypoglycemic attacks onset). Groups II, III and IV were given an additional 15 cm 3 50% dextrose (7. 5 g) i. v. infusion for each hypoglycemic attack developed. Following the toxic dose, animals were given the amount of dextrose used before and after octreotide administration and the number of hypoglycemic attacks were recorded.
section_name: Methods

section_content: There was a significant difference between Groups I, II, and IV in the number of hypoglycemic attacks and the number of dextrose requirement between 9 and 24 hours (P = 0. 001). Groups receiving octreotide showed less hypoglycemic attacks and dextrose requirements than controls.
section_name: Results

section_content: Our experience suggests that octreotide may be used to reduce the number of refractory and recurrence hypoglycemic attacks developing due to overdose of sulfonylurea; large prospective studies would be needed to validate these findings. Results Increasing concentrations of glucose, mannitol and urea resulted in a significant increase of IL-6 and IL-1β cytokine production. Insulin had no effect (Table 1 ). Conclusion High concentrations of glucose, mannitol and urea lead to a significant increase in IL-6 and IL-1β cytokine production by PBMC in vitro. The most profound effect was seen with hyperglycemia. Besides hyperglycemia, also uremia and high osmolarity seem to augment inflammation. Insulin could not reverse the increase in inflammation. These findings may be relevant in explaining the beneficial effects of normoglycemia on the inflammatory response in critically ill patients. Introduction Intensive insulin therapy reduces morbidity and mortality in postoperative critical care; however, this treatment also increases the risk of hypoglycemia. A possible cause for unstable blood glucose (BG) levels could be a variable adsorption of insulin at plastic material of infusion tubings. We evaluated in vitro and in vivo the adsorption of insulin at standard tubing materials (polyethylene (PE) and polyurethane (PU)) and the effects of this adsorption process on blood glucose levels. Methods (1) In vitro, a standard perfusor syringe (Perfusor ® ; BBraun, Germany) was filled with 50 IE normal insulin (Actrapid ® ; NovoNordisk, Germany) dissolved in 50 ml saline 0. 9%. The syringe was connected to PE or PU tubings (BBraun) and, at an infusion rate of 1 ml/hour, the insulin concentration in the syringe and at the end of the tubings was measured at hourly intervals for 5 hours and again after 24 hours by the Bradford protein assay. Insulin concentrations were compared using the Student t test.
section_name: Conclusion

section_name: Critical

section_content: (2) In a prospective, double-blinded, cross-over study, approved by the ethics committee, 10 patients on the surgical ICU received insulin via PE or PU tubing each for 24 hours in random sequence. All blood BG values, total infused insulin solution volume, and critical care scores were documented and statistically analysed by the Wilcoxon test. 

Results (1) The insulin concentration in all syringes was always >97% of the estimated value. The initial concentrations of insulin at the end of PE and PU tubings were lower than expected (23 ± 4% of anticipated concentration in the first 6 min). In PE, the concentration rose to 37 ± 2% and in PU to 78 ± 4% after 24 hours (P < 0. 0001). (2) In vivo the mean BG values did not differ between PE and PU (PE 141 ± 17 mg/dl; PU 132 ± 23 mg/dl (not significant)). Severity of illness was not different between the groups: TISS 37 ± 5 (PE) vs 39 ± 5 (PU), SAPS 43 ± 13 (PE) vs 41 ± 15 (PU) on both days; neither were catecholamine doses and 24-hour fluid balance. However, significantly more insulin solution was infused in PE (66 ± 18 ml/ 24 hours) compared with PU (44 ± 15 ml/24 hours) (P = 0. 0015). Conclusion Infusion of insulin using PE and PU tubings leads to a relevant adsorption of the drug in both materials. Adsorption to PE is significantly higher compared with PU. Thus, a large variation of insulin application to the patient is possible if different tubing materials are used. Furthermore, variability of adsorption, a competitive adsorption with other drugs if insulin is not infused via a single line as well as changes of effective insulin application following routine change of tubings, may be one cause of unexpected hypoglycemia that can be deleterious to the patient. Introduction Hyperglycemia in critically ill patients is frequently related to a hypermetabolic stress-response and has been associated with increased morbidity and mortality. The aim of this study was to assess the relationship between blood glucose levels and clinical outcome in a mixed cohort of critically ill patients with a nosocomial bloodstream infection (BSI). Methods A retrospective observational cohort study was conducted including 130 adult patients with a microbiologically documented BSI admitted over a 2-year period (2003) (2004) to the ICU. Blood glucose levels were evaluated from 1 day prior to onset of BSI (d-1) until 5 days after onset of BSI (d+5). The contribution of hyperglycemia, divided into three subgroups (≥150 mg/dl, ≥175 mg/dl, and ≥200 mg/dl, respectively), to inhospital mortality was estimated by logistic regression.
section_name: P123 Insulin therapy inhibits poly(ADP-ribose)polymerase activation in endotoxin shock

section_name: P128

section_content: The mean age of the study population was 54. 7 ± 19. 0 years. Inhospital mortality was 36. 2%. Hyperglycemia (≥175 mg/dl and ≥200 mg/dl) was observed more often among the nonsurvivors. Over the seven study days, no differences were found in daily morning blood glucose levels between survivors (n = 83) and nonsurvivors (n = 47) (all P > 0. 05). Although in the nonsurvivors the evolution of glycemia tended to be higher, this trend was not statistically significant compared with the survivors. Multivariate logistic regression revealed that age (P = 0. 022), APACHE II score (P = 0. 003), antibiotic resistance (P = 0. 001), and hyperglycemia (≥200 mg/dl) upon onset of BSI (P = 0. 001) were independently associated with inhospital mortality, whereas appropriate antimicrobial therapy ≤24 hours (P = 0. 016) and previous history of diabetes (P = 0. 022) were associated with better outcome. Conclusion Trends of blood glucose levels were higher among nonsurvivors. Hyperglycemia (≥200 mg/dl) upon onset of nosocomial BSI adversely affects outcome in a heterogeneous ICU population. Introduction Intensive insulin therapy to establish normoglycaemia reduces mortality and morbidity in critically ill patients. Frequent glucose monitoring is restricted in critically ill patients due to the high workload that has to be performed by the staff. Hence the usage of an automated discontinuous venous blood sampling system might be an alternative to improve the adjustment of the insulin therapy. The primary aim of the study was to investigate whether the glucose concentration in manually withdrawn blood samples correlates with automated withdrawn blood samples. Methods In a 12-hour trial, six volunteers were investigated (male/ female 5/1; age 28. 2 ± 2. 2 years, BMI 22. 5 ± 1. 3, nondiabetics). A 75 g OGTT was performed to enable a better dynamic range of the glucose values. Two venous cannulae were inserted into the dorsal hands for reference measurement and for connection to the automated blood sampling system. To reduce the volunteer's health risk, pressure, air bubble sensor and flushing fluid monitoring were integrated into the system. Blood samples were obtained frequently in 15/30-minute intervals. Roche Microsamplers and the OMNI S6 glucose analyser were used for determination of the blood readings.
section_name: Results

section_name: P129 System for automated discontinuous venous blood withdrawal for glucose determination of patients in the intensive care unit

section_content: The automated blood sampling system performed its operation in all volunteers over the whole trial period. The median Pearson coefficient of correlation between manual and automated withdrawn blood was 0. 983 (0. 862-0. 995). Furthermore, the results (173 data pairs) were analysed via the recently published 'Insulin Titration Error Grid Analysis' and 99. 4% were suggesting an acceptable treatment. The results of the traditional 'Error Grid Analysis' showed that 96% of the data were in zone A and 4% in zone B.
section_name: Results

section_content: The automated discontinuous blood withdrawing system provides reproducible blood samples from peripheral venous blood. In combination with a glucose sensor and an algorithm it might be used in future as a closed loop system for insulin and glucose infusion at the ICU.
section_name: Conclusion

section_content: Evaluation of the clinical effectiveness of a computerised decision-supported intensive insulin therapy regimen R Shulman, N Shah, P Glynne, R Greene, SJ Finney University College Hospital, London, UK Critical Care 2007, 11(Suppl 2):P130 (doi: 10. 1186/cc5290) Introduction It has been proposed that intensive insulin therapy (IIT) aiming for a blood glucose (BG) of 4. 4-6. 1 mmol/l reduces mortality in critically ill patients when compared with conventional insulin therapy (CIT) targeting BG at 10. 0-11. 1 mmol/l. Difficulties with IIT include inadvertent hypoglycaemia and low efficacy at achieving the target BG. We proposed that computerised decision support may mitigate these problems. Objective To comprehensively describe BG and outcome from decision-supported IIT. Methods A clinical information system at each bedspace guided staff through the IIT algorithm. The time spent within glucose ranges was calculated assuming a linear trend between successive measurements. Results Patient characteristics are shown in Table 1. The IIT group had more frequent BG evaluation (7,007 over 8,944 patient-hours, 0. 78 tests/hour) than the CIT group (3,609 over 8,617 hours, 0. 42 tests/hour). The median (interquartile range (IQR)) proportion of time spent in the target range 4. 4-6. 1 mmol/l was similar in the IIT and CIT groups (23. 21% (15. 4-29. 8) vs 17. 9% (9. 8-29. 3), respectively; P = 0. 17). Similarly, time spent with a BG between 6. 2 and 7. 99 mmol/l was no different for the two groups (48. 5% (IQR 36. 9-59. 3) for IIT and 43. 9% (IQR 34. 7-60. 9), P = 0. 72). In the IIT and CIT groups, five and six patients experienced a BG below 2. 2 mmol/l, respectively. Discussion Computerised decision-support and more intensive monitoring did not improve BG control or reduce the incidence of hypoglycaemia.
section_name: P130

section_content: Glargine insulin: an alternative to regular insulin for glycemic control in critically ill patients M Bhattacharyya, SK Todi, A Majumdar AMRI Hospitals, Kolkata, India Critical Care 2007, 11(Suppl 2):P131 (doi: 10. 1186/cc5291) Introduction The objective of this study was to determine the efficacy and safety of subcutaneous (s. c. ) once-daily (OD) glargine insulin, a long-acting insulin, in comparison with a s. c. regular insulin, based on a protocolized sliding scale regimen for achieving glycemic control in patients admitted to the ICU. Methods One hundred patients admitted to the ICU with an admission capillary blood glucose (CBG) >150 mg/dl (8. 3 mmol/l) were involved in this prospective, randomized study. Patients with age <18 years, pregnancy, shock, requiring continuous intravenous insulin infusion, renal failure were excluded. Patients were randomly assigned to receive either s. c. glargine insulin 10 U (CBG ≤ 9. 9 mmol/l) or 18 U (CBG ≥ 10. 1 mmol/l) s. c. OD (Group G, n = 50), or s. c. regular insulin based on a 6-hourly sliding scale (Group R, n = 50). CBGs were recorded at 6-hour intervals up to 96 hours or until ICU discharge, whichever was earlier. The target CBG in both groups was <150 mg/dl (8. 3 mmol/l). Patients in group G received rescue doses of regular insulin, as required. Demographic characteristics, mean and median CBG, and episodes of hypoglycemia were studied. Results Demographic profiles were comparable between the two groups. There was no significant difference in mean CBG in both groups (Group G 152. 1 mg/dl (8. 4 mmol/l), Group R 149. 9 mg/dl (8. 3 mmol/l), P = 0. 66). Median CBGs were comparable at 6hourly time points in both the groups except at 0 and 6 hours in the glargine arm (CBG at 0 and 6 hours, Group G 10. 0 mmol/l and Median capillary blood glucose (CBG) at different time points. S53 9. 9 mmol/l, Group R 9. 4 mmol/l and 8. 3 mmol/l, P = 0. 04 and 0. 02, respectively) (Figure 1 ). There were three episodes of hypoglycemia in Group G and one in Group R, which were corrected. Consequently, many healthcare bodies proposed guidelines for the control of hyperglycemia in the ICU. However, the patchy evidence underpinning these guidelines and a high rate of complications lead to controversy about the optimal glucose target range.
section_name: P131

section_content: Studies showing insulin infusions are effective have reported average glucose values at single time points. However, single time points are difficult to interpret as they do not provide information about the proportion of glucose measurements that need to be in range for benefit. We hypothesized that blood glucose variance was greater if all glucose measurements were considered and asked whether there was a diurnal pattern that accounted for some of the variance. Methods Prospective collection of all glucose measurements for ICU patients receiving an insulin infusion protocol between 20 May 2006 and 6 August 2006 in 64 ICU beds at a teaching hospital. 

We report glucose values from all ICU patients, ≥8 hours after infusion initiation.
section_name: Conclusion

section_content: We compared the 6:00 a. m. glucose value with those collected at all other times in 149 consecutive patients. The 6:00 a. m. values were lower than the remaining values (mean ± SD: 112 ± 30 mg/dl (n = 477) vs 119 ± 35 mg/dl (n = 10,364); P < 0. 0001) and as hypothesized had a smaller variance by F test (P < 0. 0001). Inspection of the time-averaged data (±SE) revealed a diurnal variation in the blood glucose with peaks occurring at 11:00 a. m. and 10:00 p. m. (Figure 1 ). This diurnal pattern may account for some of the observed variation in insulin requirements and contribute to episodes of hypoglycemia in the critically ill. there was a relationship between the total insulin dose and the time to achieve three consecutive glycaemic controls (r = -0. 43, P = 0. 023). Also, between the total insulin dose and mean blood glucose r = 0. 508, P = 0. 001. There was no significant relationship between the total insulin dose and indication for ICU admission, and the total insulin dose and body mass index. Conclusion Findings from this study showed that the indication for admission did not affect either the total dose of insulin required to achieve glycaemic control or the time it takes to achieve three consecutive glycaemic controls. Method Over a 7-month period all patients staying longer than 48 hours in the ICU with hyperglycaemia (>150 mg%) on three consecutive measurements were included in the study. These patients were treated according to a protocol at the discretion of the attending nurse. On daily rounds and every 4-5 weeks supervision was performed, and the protocol was modified three times during this period according to staff comments. Further on, medical as well as nonmedical problems of implementation were analysed and discussed. Attitudes and perceived impeding aspects of the implementation process were recorded by means of a questionnaire. Results Since insulin sensitivity showed enormous variability, glycaemic control required a high nursing effort. Impeding aspects to titrate blood glucose into the target range were the absence of a nutritional protocol (high carbohydrate intake, despite inflammation/infection leading to hyperglycaemia that was difficult to control) and fear of hypoglycaemia (<60 mg%) leading to low-dose insulin with consecutive hyperglycaemia. Lack of communication (and therefore a loss of information) between critical care nurses and the intensivists and poor acceptance from physicians to leave this field of intensive care medicine to the nurses were additional factors that slowed the implementation process. Conclusion Implementation of protocol-driven medicine requires a high quality of information flow. The lack of linearity between blood glucose and insulin dose (variability of insulin sensitivity) required a sometimes intuitive (experienced) decision to titrate the insulin dose. The conflict of physicians with this new role of critical care nurses might be due to the lack of understanding of the evolution of the nursing profession.
section_name: Results

section_name: P136 Implementation of glycemic control -problems and solutions

section_content: Computer-advised insulin infusion in critically ill patientsa randomized controlled trial Introduction Tight blood glucose (BG) control has been shown to decrease morbidity and mortality in patients in the surgical ICU [1] but is difficult to achieve using standard insulin infusion protocols. 

We previously evaluated a software model predictive control (MPC) insulin administration algorithm in postcardiac surgery patients [2]. This study investigated the use of an enhanced MPC algorithm (eMPC) in more severely ill patients over 72 hours. Methods Fourteen (seven male) critically ill ventilated medical and surgical patients, mean age 65 years, with an arterial BG > 6. 7 mmol/l within 24 hours of ICU admission (RBH) or already receiving insulin infusion, and expected to require mechanical ventilation for more than 72 hours, were treated either with BG control by the standard ICU insulin intravenous infusion protocol [2] or eMPC-advised insulin infusion (n = 6) for 72 hours.
section_name: P137

section_content: The use of MPC improved BG and the HGI. This improvement was accompanied by an increased sampling frequency. MPC with time-variant sampling is a reliable tool for the implementation of TGC in patients in the medical ICU.
section_name: Conclusion

section_content: The effect of tighter glucose control on outcome
section_name: P139

section_content: The unit is a 10-bed closed-format medical-surgical ICU in a general hospital. Starting in 2003 insulin was prescribed to ICU patients using several nurse-driven computerised protocols, each subsequent protocol aiming for lower glucose levels. From February 2004 until May 2005 protocol 1 was used, aiming for glucose between 5. 0 and 9. 0 mmol/l; from July 2005 until December 2005 protocol 2 was used, aiming for glucose between 4. 5 and 7. 5 mmol/l. Serum glucose was measured at 6:00 a. m. in all patients from blood derived from arterial lines or venous puncture. The rest of the day blood glucose was measured either using the Glucotouch (protocol 1) or the AccuCheck (protocol 2) devices. To eliminate differences due to these different methods of measurement, only the 6:00 a. m. glucose measurements done by the central laboratory were studied here. Data were derived from ICU and laboratory databases. 

Results See Table 1. The median morning glucose was reduced from 7. 5 mmol/l with protocol 1 to 6. 8 mmol/l with protocol 2, resulting in small but nonsignificant improvement in outcome. Subgroup analysis focusing on medical or surgical patients or on patients with specific length of stay in the ICU also revealed nonsignificant differences in outcome. Introduction Increased risk of hypoglycemia is the major drawback of strict glycemic control, which has been extensively used in critically ill patients. Fast and precise glucose measurements are therefore mandatory. Our aim was to evaluate the accuracy of two methods of bedside point-of-care testing for glucose measurements using arterial, capillary and venous blood samples in ICU patients. Methods A cross-sectional study with prospective data collection included 86 patients admitted to a 40-bed clinical-surgical ICU of a tertiary care hospital. Results from two different methods of glucose measurement were compared with central laboratory arterial blood measurements: Accu-chek Advantage ® (Roche) arterial, venous and capillary samples; and Precision PCx ® (Abbott) arterial samples. All samples were collected simultaneously. Agreement between measurements was tested with the Bland-Altman method. Results Comparisons between pairs of measurements are shown in Figure 1. Conclusions The two glucose meters evaluated might not be sufficiently reliable to be used in the ICU setting, especially for patients under strict blood glucose control. Moreover, there are marked differences between the equipment and a decrease in precision if capillary or venous samples are used. Results Correlation between the reference method and both GM in the overall BG range was reasonable, but not perfect (r 2 ≥ 0. 93). This was further underlined by BA analysis (Figures 1 and 2 ), showing a bias to overestimate BG with GM. In the TGC range (80-110 mg/dl) correlation was low for both GM (r 2 ≤ 0. 66). This was confirmed by BA analysis, demonstrating broad limits of agreement: +14. 2 and -26. 6 mg/dl for Accu-Chek ® and +5. 5 and -31. 1 mg/dl for HemoCue ®. Conclusions The accuracy of the tested GM in our ICU patients was insufficient for safe clinical practice. Therefore, to avoid potentially harmful hypoglycaemia, caution is warranted when TGC is implemented exclusively based on BG results obtained by GM.
section_name: Patients and methods

section_name: P141

section_content: A Roman, A Janier-Dubry, C Hanicq, P Flament, F Vertongen, E Stevens CHU Saint-Pierre, Brussels, Belgium Critical Care 2007, 11(Suppl 2):P142 (doi: 10. 1186/cc5302) Introduction Bedside capillary or arterial blood glucose monitoring is mandatory for ICU patients under tight glycemic control. Pointof-care methods are based on glucose-oxidase (GO) or glucosedehydrogenase (GD) enzymatic methods whereas the laboratory reference method is hexokinase for measuring the plasma glucose levels. Methods In this prospective observational study, blood glucose was simultaneously measured on the Glucocard Arkray (GO, capillary), on the Accu-chek Inform Roche (GD, capillary and arterial) and on the Rapid-Lab 1265 Bayer (GO, arterial), and each value was compared with the reference laboratory result. Results A total of 262 matched analyses were done in 60 patients. Biases are defined as the glucose laboratory value minus point-ofcare value. The bias, 95% limits of agreement, and numbers of observed discrepancy (d) paired results >20% and >10% are reported in Table 1. Conclusions GO methods underestimate while GD methods overestimate all blood glucose levels as compared with plasma glucose levels measured by the reference method of hexokinase. Capillary methods have wider 95% limits of agreement than measures carried out on arterial blood. 

Introduction The objective of this study was to investigate whether continuous glucose monitoring for intensive care patients could be implemented using blood microdialysis (MD) as tight glycaemic control reduces mortality and morbidity of critically ill patients. Currently investigated is whether the subcutaneous tissue is an adequate and representative site for glucose monitoring. We have designed and tested a novel system that allows continuous measurement of glucose concentration in whole blood based on MD. Methods Na-heparin is pumped to the tip of a double lumen catheter and the blood-heparin mixture is withdrawn continuously at a mixing ratio of 1:1 at a flow of 4 ml/hour. The blood-heparin mixture is microdialysed in a planar flow-through MD unit and is discarded thereafter. The dialysate is collected and analysed for glucose concentration via Beckman analysis and referred to venous blood samples taken from the reference arm. Eight healthy volunteers underwent a 12-hour investigation including an OGTT. Glucose readings from dialysate and venous blood were obtained in a 15-30 minute interval. Results All eight subjects successfully completed the 12-hour trial. The coefficient of correlation between continuously withdrawn microdialysed blood and venously taken reference blood samples was r = 0. 9834 (0. 9753-0. 9958). The Clark Error Grid Analysis (EGA) revealed that 99. 5% of all data pairs are in the A range (220 of 221). Applying the novel Insulin Titration EGA yielded in 100% of data pairs the 'acceptable treatment' area. Conclusions Blood MD based on continuous blood withdrawal and extracorporeal MD is a promising approach to obtain dialysate reliably, safely and continuously for long-term determination of blood glucose concentration with online sensors. The correlation between glucose concentration of dialysate and reference venous blood samples is excellent. The patency of the double lumen catheter in the current form could be improved by introducing Available online http://ccforum. com/supplements/11/S2 1. HE was more than 300 in 70% of the 570 measurements. Blood sugar was between 6. 3 and 6. 9 mmol/l. Gastro Prokinetics was used in 80%. There was no feeding protocol in the unit and low GRVTs were used before abandonment of the enteral regime. Introduction For critically ill patients unable to eat, enteral tube feeding (ETF) is the preferred mode of feeding. The study aimed to investigate the amount of enteral feed obtained by patients on ICU in a busy London Teaching Hospital, the efficiency of initiation of feeding, and possible reasons for the failure of the above. Methods A prospective observational study was carried out over 1 month on patients admitted to a general and cardiothoracic ICU, who received ETF. Baseline data including age, reason for admission and illness severity score (SOFA) were documented. 

Length of time from admission to start of feeding was noted, and the volume of feed delivered to patients was recorded. The quantity of calories delivered to the patient was compared with the patient's ideal nutritional requirement (determined by the ICU ETF protocol). Feeding interruptions were also recorded.
section_name: P142 Comparison of accuracy of glucose-oxidase-based and glucose-dehydrogenase-based point-of-care glucometers

section_content: Fifty-two patients receiving ETF were observed for a total of 7,349 hours: 67. 3% of patients were surgical and 32. 7% medical. Patients received a median of 75% of their ideal calorific requirement. Feeding was started a median of 15 hours after admission, and a median of 5% of feeding time was interrupted after ETF had been started. Reasons for interruption included high gastric aspirates, starvation for procedures and displacement/ blockage of feeding tube. The time to start ETF was significantly different according to admission categories (P = 0. 033), with abdominal and cardiothoracic surgical patients having the greatest delays. Abdominal surgical patients also had a higher proportion of feeding interruptions due to high gastric aspirates and starvation for procedures. The SOFA score on day 1 significantly correlated with the time taken to start feeding (P = 0. 008), length of total feeding interruption (P = 0. 012), length of feeding interruption due to high gastric aspirates (P = 0. 043), and length of feeding interruption due to starvation for procedures (P = 0. 026).
section_name: Results

section_content: The majority of patients received a high proportion of their ideal calorific requirement and began feeding within 24 hours. 

The data indicate that patients having had abdominal surgery or the sickest patients may be may be more likely to experience delays in initiation and interruptions to feeding. neurotrauma ITU (ITU3), concurrent with increased PPI usage. We believe this worthy of further investigation. Objective A retrospective study to assess the incidence and causal factors associated with long-term dysphagia following intensive care discharge. Methods A questionnaire was sent out 4 months post ICU discharge to 193 intensive care patients (Level 3 care with a stay of over 48 hours). We reviewed the case notes of those patients who reported swallowing difficulties to establish whether they had undergone, had any characteristics of or received therapies potentially associated with dysphagia.
section_name: Conclusion

section_name: P148 Proton pump inhibitors and the incidence of Clostridium difficile on the intensive care unit

section_content: We had a 50% response rate to our questionnaire. An overall dysphagia post ICU stay rate of 19. 5% was observed. Fever and age over 65 were both common findings as one may expect and showed the highest association with subsequent dysphagia. We did not find any suggestion of a relationship between changing tracheostomy (suggesting repeat procedures) and subsequent difficulty swallowing. One patient within this group subsequently developed a tracheal stenosis. See Table 1.
section_name: Results

section_content: We found the percentage of patients reporting swallowing difficulties post percutaneous tracheostomy (PCT) (Portex Blue Line Ultra tracheostomy tube) to be higher than one would expect. This may be confounded by neurological injury necessitating the need for a PCT, but we feel this may be an area of concern meriting further investigation given frequent PCT in ICU practice.
section_name: Conclusion

section_content: The reasons for the typical bowel dysfunction following traumatic injury are unclear. Corticotropin-releasing factor (CRF) in peripheral blood/tissue may induce intestinal barrier dysfunction via receptor-mediated mechanisms independently of the hypothalamic-pituitary-adrenal axis. This mechanism seems to involve interactions of CRF with enteric nerves and mast cells, which results in increased gut intercellular tight junction permeability to macromolecules, as well as increased epithelial cell apoptosis leading to loss of mucosal integrity. We investigated whether blood and intestinal tissue CRF is associated with postoperative gut dysfunction in shock. 

Methods CRF analysis was performed on full-thickness bowel specimens obtained from shocked trauma patients requiring emergency abdominal surgery for penetrating injury, and from patients undergoing small bowel resection during elective bowel surgery. Venous blood was taken before anaesthesia, intraoperatively and on postoperative day 1. CRF extracted from tissue and blood was quantified using radioimmunoassay. On day 1 postoperatively, intestinal permeability was tested by urinary lactulose:mannitol (L:M) measurement. Institutional ethical approval was granted and patients gave written informed consent. 

Results Trauma patients (n = 6, male/female = 6/0, age 27 ± 10. 2 years, ISS 23 ± 6. 8) were younger than elective patients (n = 6, male/female = 4/2, age 52. 8 ± 7. 7 years, P < 0. 0006), and had significantly lower mean tissue [CRF] (0. 034 ± 0. 015 x 10 -3 % total protein (TP)) than elective patients (0. 117 ± 0. 075 x 10 -3 %TP, P = 0. 023). The median (IQR) intraoperative blood CRF level was higher in trauma patients (86. 7 (5. 5) pg/ml vs 59. 8 (9. 6) pg/ml, P = 0. 03) than elective patients. In trauma patients this correlated negatively with postoperative L:M (r = -0. 9, P = 0. 037), although intestinal permeability was greatly and equally increased in both groups (combined mean ± SD L:M, 0. 58 ± 0. 55). 

Conclusions CRF is detectable in bowel tissue following trauma and is significantly lower in trauma vs elective surgery patients, while CRF in blood may be a factor associated with gut barrier changes following shock and emergency laparotomy.
section_name: Introduction

section_name: P151

section_content: (EN). In the ICU, however, the use of sedation, 24-hour feeding and proton pump inhibitors can make the standard confirmatory methods recommended by the UK National Patient Safety Agency (UKNPSA) [1] unreliable, and result in the need for multiple chest X-rays (CXR), increased cost and feeding delay. We studied the role of the Cortrak ® (Viasys MedSystems, USA) against standard practice, and assessed the following outcomes: time required to confirm correct NGT position, time to starting feeding, and potential cost savings. Methods We enrolled patients admitted to our ICU who required NGT insertion for EN. A Corflow NGT with Cortrak stylet was inserted, and the position monitored using the Cortrak magnetic sensor. The Cortrak system tracks the trail of the stylet tip as it progresses towards the stomach and provides a visual representation of the NGT position on a video screen, allowing rapid determination of insertion success. The position of the NGT was also assessed using pH paper and/or CXR, as appropriate, according to the standard UKNPSA guidelines. Data were analysed using a paired t test and time-to-event analysis. Background The aim of this study was to determine the effect of propranolol on infections and clinical parameters during the acute phase postburn. Severe thermal injury is followed by a period of hypermetabolism that is directly proportional to the size of insult sustained. Infection and multiorgan failure are now the leading cause of death from severe thermal injuries. Propranolol, an anticatabolic agent, improves hypermetabolism postburn. However, there is evidence that propranolol worsens immune function and increases the incidence of infection in critically ill patients. Methods Sixty-six patients with burns >40% total body surface area were enrolled into the study and randomized to receive standard burn care (controls, n = 33) or standard burn plus propranolol for more than 21 days (propranolol, 0. 5-1. 5 mg/kg every 6 hours, n = 33). Biopsies were taken three times a week for microbiological determination. Clinical parameters were collected and blood was drawn at regular intervals throughout the hospital course and analyzed for IGF-1, IGFBP-3, and HGH. Patients underwent weekly resting energy-expenditure measurements. Statistical analysis was performed using analysis of variance with Bonferoni's correction and Student's t test where applicable.
section_name: S61

section_content: Propranolol treatment reduced heart rates by 10% and significantly improved stroke volume throughout the acute hospital stay compared with controls (P < 0. 05). Resting energy expenditure was significantly decreased in the propranolol group when compared with controls at discharge (P < 0. 05). Infection rates on admission were the same for both groups (17% propranolol vs 22% control). The incidence of infection throughout hospital course was significantly lower in the propranolol group (60%) compared with controls (87%) (P < 0. 05). Propranolol significantly increased IGF-I, IGFBP-3, GH, and prealbumin, while it significantly decreased CRP and fatty acids (P < 0. 05). 

Conclusions Following a severe burn, propranolol attenuates infections, inflammatory markers and fatty acid levels while improving cardiac work and endogenous anabolic hormone levels. 

We suggest that propranolol is a safe and efficacious modulator of the postburn response.
section_name: Results

section_content: The study investigates the effect of early enteral immunonutrition on patient recovery after extensive elective surgery in the upper abdomen [1, 2]. It investigates the speed of patient recovery administering early enteral immunonutrition combined with total parenteral nutrition [3].
section_name: Introduction

section_content: The total of 40 patients who had undergone this type of surgery were involved in this study. Near the end of the surgery procedure a percutaneous jejunostomy was performed in 20 patients (G1), and enteral nutrition started on the first postoperative day with small doses of immunonutrient (Reconvan) 10 ml/hour. After every 12 hours the tolerance was estimated (abdominal distension, diarrhoea, vomiting). After every 24 hours the immunonutrient dose was increased by 20 ml/hour until we reached the maximum of 80 ml/hour. In the first three postoperative days the patients were also administered total parenteral nutrition, and after that only enteral nutrition. The other group of 20 patients (G2) was administered only parenteral nutrition from the first postoperative day. Preoperatively, every patient was measured for body weight, body height and body mass index, and using laboratory tests we established the levels of albumin, transferine, blood urea nitrogen and creatinine. On the third and ninth postoperative days we repeated the same laboratory tests, and measured the daily loss of nitrogen by excretion of urea in urine.
section_name: Materials and methods

section_content: Patient recovery was faster in G1. The average patient stay in ICU was 5 ± 1 days (G1) vs 10 ± 2 days (G2). The average hospital stay was 22 ± 3 days (G1) vs 29 ± 5 days. Peristalsis was detected on the third day as an average (G1) vs 4. 5 days (G2). A decrease in pulmonary complications was achieved in G1 (one pleural effusion) vs G2 (eight pleural effusions). Laboratory tests show that patients in G1 are in lower catabolism compared with G2 patients. Conclusion Early enteral immunonutrition through jejunostomy is an efficient and safe method of patient nutrition with fewer postoperative complications, and also accounts for a hospital cost decrease of 50%. 

Introduction A large randomized trial is needed to evaluate the safety and efficacy of glutamine (GLN) and antioxidant (AOX) supplements. However, high doses of such nutrients via enteral and parenteral routes early in the course of critical illness is often interrupted by high illness acuity and other treatment priorities. The purpose of this pilot trial was to evaluate the feasibility of delivering high-dose GLN and AOX supplements early on in the course of critical illness, and to estimate recruitment for the larger REDOXS study. Methods In six Canadian centers, using a 2 x 2 factorial design, we randomized mechanically ventilated adults who had two or more organ failures within 24 hours of ICU admission to one of four groups: (1) GLN (0. 35 g/kg/day i. v. plus 30 g enterally), ( 2 ) AOX (500 µg selenium i. v. and 300 µg selenium, 20 mg zinc, 10 mg β-carotene, 500 mg vitamin E, and 1,500 mg vitamin C enterally), (3) both AOX + GLN, and (4) placebo. Supplementation was continued for a minimum of 5 days up to 28 days and was provided independent of nutrition support. We recorded the time from ICU admission to randomization, the time to start of supplements and nutrition support parameters.
section_name: Results and discussion

section_content: From April 2005 to April 2006, 80 patients were randomized (average 2. 1/site/month). The median time from ICU admission to randomization was 18. 2 hours (range 11. 6-21. 1 hours). 

All patients received parenteral supplements, the median (range) time to start was 2. 7 hours (2. 0-3. 8 hours) and 78/80 (98%) received enteral supplements with a median (range) of 2. 6 hours (1. 9-4. 5 hours) from randomization. The mean duration of supplements was 11. 1 days (enteral) and 12. 2 days (parenteral). 

The mean volumes of enteral and parenteral supplements received were 84% (range 45-102%) and 93% (range 54-100%) prescribed volumes, respectively. The average prescribed energy and protein intakes were 1,802 kcal/day and 86 g protein/day but the average daily percentage energy and protein received from nutrition support was only 65% (range 4-95%) and 62% (range 2-97%) of that prescribed, respectively.
section_name: Results

section_content: In critically ill patients with organ failure we provided adequate amounts of study supplements via both enteral and parenteral routes in the early phases of acute illness, independent of nutrition support. We estimated recruitment of at least two patients/site/month for our future trial. 

Introduction Standard selenium (Se) substitution (30-75 µg/day; 0. 4-0. 9 µmol/l) in the critically ill is not sufficient for a sustained plasma level (0. 58-1. 82 µmol/l; 46-143 µg/l). Standard Se substitution keeps the plasma level in the range 0. 28-0. 42 µmol/l. High-dose Se substitution correlated with a decrease in mortality of patients with SIRS. The influence of high-dose substitution on selected parameters, MAP and mortality in the critically ill were evaluated in a prospective randomized clinical trial. Methods One hundred and twenty-three patients (78 males, 45 females, median age 62. 7 and 60 years, respectively) were randomized into group A (SOFA 19. 27) and group B (SOFA 10. 23). Group A received standard Se substitution: 30-75 µg NaSelenite i. v. /day. Group B received high-dose Se substitution according to a protocol: 1,000 µg at day 1, followed with 500 µg at days 2-14 of NaSelenite i. v. The plasma levels of Se, prealbumin, albumin, CRP, PCT, cholesterol, gluthathionperoxidase GSHPx, D-dimer, creatinine clearance and leucocytes were examined daily. MAP trends and 28-day mortality were evaluated as clinical markers. 

Results The Se plasma level was significantly higher in high-dose Se-substituted patients (0. 56 µmol/l vs 0. 88 µmol/l, P < 0. 001). 

GSHPx was significantly higher in high-dose Se-substituted patients (4,864 U/l vs 6,097 U/l, P < 0. 001). No significant differences were found in the level of albumin, prealbumin, CRP, PCT, leucocytes, fibrinogen, cholesterol, D-dimer and creatinine clearance and MAP. The 28-day mortality was lower in a high-dose Se-substituted patients (33% vs 37%), but not significantly.
section_name: Conclusion

section_content: The critically ill have an increased demand for Se, which is essential for synthesis of Se enzymes and Se proteins. The increased demand for Se is not covered by standard substitution. High-dose Se substitution (500-1,000 µg/day) normalizes its plasma level and increases the GSHPx plasma level. High-dose Se substitution has no adverse reactions. The decrease of 28-day mortality in high-dose Se-substituted patients is not significant. The trial on high-dose Se substitution further continues.
section_name: Conclusion

section_content: Magnesium deficiency in the surgical intensive care unit
section_name: P156

section_content: One hundred and sixty-six patients were included in this analysis. Among the main results, 63. 69% were males and 77. 78% were considered malnourished. The mean SOFA score was 6. 21, with a mean APACHE II score of 19. 39. In total, 97. 23% of the PN used in Brazil were manufactured by third-party companies and this was associated with a significant delay in the beginning of the infusion (median time 29. 76 hours), and elevated in-ICU (50%) and inhospital (55. 17%) mortality rates. A total 24. 29% of the patients were immunosuppressed. The most used lipid source was long-chain triglycerides/medium-chain triglycerides (80. 69%). 

Conclusions The use of PN in Brazil is associated with a significant delay in the start of infusion and high mortality rates. The most used lipid emulsion (long-chain triglycerides/medium-chain triglycerides) has been associated with more apoptosis [2] and compromised lymphocyte proliferation [3]. The overall findings of these study indicate that strategies to reduce the delay in start of PN and the use of better lipid sources must be adopted to provide better assistance for patients in need of PN in Brazil. Acknowledgement Supported by a research grant from Baxter Hospitalar Ltda. Introduction Ultrasound (US) significantly facilitates central venous catheterization, reducing the percentage of failure, the percentage of accidental arterial puncture, and the percentage of complications (haematoma, haemothorax, pneumothorax). Nonetheless, it is not clear whether US guidance (USG) (so-called 'dynamic' or 'real-time' US techniques: that is, venipuncture under direct US control) may be better than US assistance (USA) (socalled 'static' or 'indirect' US techniques: that is, US imaging of the vein, with or without skin marking, and then blind venipuncture). Methods From February 2005 to September 2006, our CVC Team adopted the following protocol for internal jugular vein (IJV) catheterization: (a) both IJVs were evaluated to assess position, dimensions, and other features known to affect the risk of catheterization; (b) then, a decision was made whether to continue with USA or USG; (c) the IJV was accessed via the low lateral Jernigan approach; (d) after two failed USA attempts, USG venipuncture was adopted; (d) when IJVs were not available, USG venipuncture of other central veins was the second choice; and (e) fluoroscopy was used only in paediatric patients, but all patients had a postoperative chest X-ray to rule out pneumothorax and malposition. Results In 20 months, 821 central venous catheters (CVCs) were inserted in adults (181 short-term CVC + 218 tunnelled + 316 ports) and in paediatric patients (age range 20 days-13 years, average 5. 5 years: 20 short-term + 84 tunnelled + two ports). In adults, the procedure started as USA in 522 and as USG in 299 cases: a shift from USA to USG was necessary in 8%. USG was the first choice in all paediatric cases. The IJV was successfully cannulated in most adult patients, with very few exceptions (innominate vein in 12 cases, axillary vein in two cases, femoral vein in one case, all by USG). In one paediatric patient, the CVC was inserted in the subclavian vein, via a supraclavicular USG approach. Complications were: failure 0%; pneumothorax 0%; haemothorax 0%; accidental arterial puncture 1. 1% (1. 7% USA vs 0. 3% USG); haematoma 0. 4% (only for USA); malposition (0. 8%, exclusively with the left IJV).
section_name: Results

section_content: In conclusion, (a) we had a minimal incidence of complications, (b) USG was associated with a relevant reduction of the risk of accidental arterial puncture and haematoma, if compared with USA, and (c) choosing the left IJV was associated with a higher risk of malposition.
section_name: Conclusion

section_content: Catholic University Hospital, Roma, Italy Critical Care 2007, 11(Suppl 2):P159 (doi: 10. 1186/cc5319) Introduction In the critically ill, a reliable peripheral or central venous access is of paramount importance. Nonetheless, access may be difficult or may carry a significant risk of complications (pneumothorax, central line infection, etc. ). Peripherally inserted venous catheters -either central (PICC) or peripheral (midline catheters (MC)) -are associated with a low risk of catheter-related bacteremia; also, using the ultrasound guidance and the microintroducer technique (UG + MIT), they can be inserted in any patient, regardless of the availability of superficial veins. We have reviewed our experience of 56 peripherally inserted catheters in 53 patients in different ICUs (surgical ICU, trauma unit, coronary unit, neurosurgical ICU, stroke unit, pediatric ICU, etc. ); all catheters were positioned at the mid-arm, in the basilic vein or in the brachial veins, using UG + MIT. We assessed the feasibility of this technique in the acutely ill and the rate of complications.
section_name: P159 Advantages of ultrasound-guided peripherally inserted venous access (PICC and midline catheters) in critically ill patients M Pittiruti, G Scoppettuolo, A LaGreca

section_content: We inserted 16 PICC and 40 MC in patients requiring prolonged venous access (estimated >15 days); nine were septic, six had coagulopathy, 21 had tracheostomy. We used both silicone and polyurethane 4 Fr catheters. Procedures were performed by a team of trained physicians and nurses. Catheter insertion was easy in most cases, and immediate complications were few (no failure; one hematoma; no arterial or nerve injury). Late complications were: one local infection; three thrombosis (two requiring removal); four cases of damage of the external catheter (due to poor nursing or to inappropriate use of the catheter during rx procedures), all easily repaired; one dislocation; no catheter occlusion; no catheter-related bacteremia. Most catheters stayed in place for a prolonged time (range 9-65 days, median 19 days); only three were removed because of complications. Conclusion Our experience with PICC and MC was characterized by an extremely low rate of infective and thrombotic complications. Venous access was achieved in any patient, even with limited availability of peripheral veins. The use of US-inserted PICC and MC should be considered when central access is not advisable or is contraindicated.
section_name: Methods and results

section_content: Department of Anaesthesia & Intensive Care Medicine, The Mid Yorkshire Hospitals, UK Critical Care 2007, 11(Suppl 2):P160 (doi: 10. 1186/cc5320) Introduction Ultrasound has been introduced in the insertion of central venous lines to reduce the complications associated with the conventional landmark technique [1]. We compared both techniques; we noted the number of attempts, the duration of insertion and complications. Methods Thirty patients were randomly selected, from the operating theatre and ICU, who required placement of a central venous catheter. The central venous catheter placement was performed by two experienced anaesthetists with more than 6 years experience in anaesthesia and intensive care. In 15 patients the internal jugular venous catheter placement was performed using the external anatomical landmark technique, and in the other 15 patients the placement was under ultrasound guidance. The duration of insertion was recorded from the moment the needle touched the skin until insertion of the catheter and removal of the guide wire. The numbers of attempts as well as immediate or delayed complications were recorded.
section_name: P160 A comparison between ultrasound-guided central venous line placement and an anatomical landmark technique M Soliman, K Ismail

section_content: The central venous catheter placement was successfully performed from the first attempt in both groups. There were no immediate or delayed complications noted; however, the mean time of insertion was longer in the ultrasound-guided group (4. 55 min) compared with the external anatomical landmark group (2 min) (Figure 1 ). Discussion Some studies have been designed to evaluate ultrasound-guided central venous catheter placement compared with the conventional method based on external anatomical landmarks. These studies demonstrated the superiority of ultrasound-guided central venous line placement over the external anatomical landmark technique. However, there was no time gain demonstrated in ultrasound-guided placement [2]. On the other hand, a number of studies have expressed several reservations concerning the systematic use of ultrasound guidance for central line placement [3]. In our patients we found that the use of ultrasound neither altered the rate of complication nor the number of attempts in central venous catheter placement. Also the duration of placement of the central line catheter
section_name: Results

section_content: The external anatomical landmark technique in central line placement is considered a safe method with experienced hands. The time of insertion of a central line using the external anatomical landmark technique was shorter than the ultrasoundguided placement method. It is essential for all trainees to be taught both methods for central line placement to be able to place a central line catheter quickly and safely in emergency situations and when an ultrasound machine is not available.
section_name: Conclusion

section_content: This study aimed to establish the prevalence of home ventilatory and respiratory support within the catchment area of Frimley Park Hospital in Surrey. The number of patients receiving respiratory support at home has been increasing nationally since 1990 [1] ; however, no local data exist. This trend is likely to continue as domiciliary ventilation gains popularity for the treatment of obstructive sleep apnoea and certain groups of COPD patients [2]. Method A postal survey was sent out to practice managers in the local catchment area. They were asked to provide data for: patients on home ventilatory support for any reason, patients with long-term tracheostomies, patients with COPD who are on home oxygen or who you would classify as end stage, and the total number of patients registered to the practice. This was followed up with a telephone call approximately 2 weeks later. Many were then emailed the same questionnaire. A further two telephone calls to each practice were made as necessary in order to obtain data.
section_name: Introduction

section_content: Out of 67 surgeries contacted, we achieved a response rate of 65%. Thirty-three practices (49%) were able to provide complete data, six (9%) provided partial data, and a further five (7%) were unable or unwilling to provide any data. Twenty-three (34%) practices did not respond. A total of 318,130 patients were listed by the responding practices. Of these: 23 patients live with long-term tracheostomies, a prevalence of 1 in 13,800; 65 patients receive mechanical respiratory support at home, a prevalence of 1 in 4,900; and 207 patients receive oxygen therapy at home, a prevalence of 1 in 1,500. Discussion This study suggests that the Frimley Park Hospital population of 350,000 currently contains about 100 individuals requiring mechanical respiratory support at home. This is of concern as currently there is no formal support for any of these high-risk patients other than ventilator maintenance.
section_name: Results

section_content: The frequency of MV was 30%; the overall and specific mortality rates were 15% and 50%, respectively. The mean (±SD) age was 57 ± 21 years; 52% were males; the mean APACHE II score was 22. 2 ± 8. 2; 69% were medical patients; the mean duration of MV was 11 ± 7. 9 days; 93% were on invasive MV. A multivariable analysis was performed to identify the variables associated with death. These included sepsis (P = 0. 02), MV duration (P < 0. 001), renal failure (P = 0. 006) prior to MV, and the following variables that occurred during the MV period: sepsis (P = 0. 004), acute lung injury/acute respiratory distress syndrome (P = 0. 001), renal failure (P < 0. 001), haematological failure (P = 0. 02) and vasoactive drug use (P < 0. 001). It should be noted that selected ventilatory monitored variables were included in the multivariate model. However, they were not associated with mortality in our study sample. Background Hypercapnia and elevated intraabdominal pressure from carbon dioxide (CO 2 ) pneumoperitoneum can adversely affect respiratory mechanics and arterial blood gases. We tested the hypothesis that adaptive pressure ventilation-synchronised intermittent mandatory ventilation (APV-SIMV) may provide better pulmonary mechanics, CO 2 homeostasis and pulmonary gas exchanges with less frequent ventilatory settings (tidal volume (TV), respiratory rate (RR)) and lower peak inspiratory pressure (P peak ) and plateau pressure (P plat ) than pressure-controlled synchronised intermittent mandatory ventilation (P-SIMV) in patients undergoing laparocopic cholecystectomy (LP).
section_name: Results

section_content: The study group consisted of 40 patients (APV-SIMV n = 20, P-SIMV n = 20). LP was performed under total intravenous anesthesia. After induction of anesthesia, a RR of 12 breaths/ minute, and an inspiratory:expiratory rate of 1:2 and PEEP of 6 cmH 2 O were set for both groups. APV-SIMV was started with a target TV of 8 ml/kg. P-SIMV was started with the inspiratory pressure (P ins ) that will provide 8 ml/kg TV. The settings were changed until target parameters to maintain normocapnia and normoxia were achieved (ETCO 2 30-35 mmHg, PaCO 2 35-45 mmHg and SaO 2 >90%). When the target parameters could not be achieved, the first RR was increased by 2 breaths/ minute up to 16 breaths/minute, then the volume or pressure was titrated to induce 1 ml/kg increases in TV up to 10 ml/kg. The initial FiO 2 was set to 50%. FiO 2 was increased with increments when the SaO 2 fell below 90%. PaO 2 /FiO 2, static compliance, VD/VT, P peak and P plat, ETCO 2, inspiratory and expiratory resistances, and arterial blood gas analysis were recorded before, during and after pneumoperitoneum. Statistical analysis were carried out using the chi-square test, paired test and independent samples test when appropriate. 

Results Demographic data were similar between groups. Pneumoperitoneum caused significant decreases in static compliance and arterial pH, and increases in P peak and P plat, VD/VT and ETCO 2 in both groups. However, APV-SIMV resulted in fewer setting changes, lower peak and plateau pressures, VD/VT, and ETCO 2 levels when compared with P-SIMV (P < 0. 025). Conclusion APV-SIMV may provide better results then conventional P-SIMV in patients undergoing LP.
section_name: Method

section_content: The influence of cycling-off criteria and pressure support slope on the respiratory and hemodynamic variables in intensive care unit patients
section_name: P165

section_content: Comparisons between different slope and cycling-off values did not result in any statistically significant changes for the evaluated variables (Table 1 ). Conclusion Changes in cycling-off criteria from 25% to 40% of the peak flow and on the pressure slope from 150 ms to 300 ms do not affect other respiratory and hemodynamic variables in mechanically ventilated patients.
section_name: Results

section_content: Introduction The clinical use of ventilators is limited due to a huge variety of different ventilation methods. The clinician -often under high cognitive load from the complicated technical equipment on an ICU -just uses a small subset of available parameter settings. The aim of the present study was to develop a closed-loop ventilation controller based on mathematical models and fuzzy logic.
section_name: P166 AUTOPILOT-BT: an approach towards automatic mechanical ventilation

section_content: The system was designed to track a desired end-tidal CO 2 pressure (PaCO 2 ), to find a PEEP leading to maximum estimated respiratory system compliance and to maintain the arterial oxygen saturation (SaO 2 ) at an optimal level. We developed a program in LabView (National Instruments, Austin, TX, USA) on a laptop that is able to read the internal data of a ventilator (Evita 4; Dräger Medical, Germany) in real time. Respiratory signals (for example, SaO 2 ) are acquired from monitoring. Discrete measurements (for example, PaO 2 ) are either assumed constant until next measurement or are interpolated using a model-based approach evaluating, for example, the etCO 2 data. The course of etCO 2 following the setting of optimal frequency was evaluated to calculate the time required for equilibration of etCO 2. 

Results A module automating the initial settings of the ventilator according to local ICU rules is realized. Modules were added that optimize breathing frequency with respect to PaCO 2 /etCO 2 and FiO 2 according to SO 2 whenever no PaO 2 is available. A lung simulator (Michigan Instruments Inc., Grand Rapids, MI, USA) connected with the LS4000 (Dräger Medical) was used to evaluate the system. Exemplary results are presented in the figures, which show the minute volume/etCO 2 relationship (Figure 1 ) and a parametric fit of etCO 2 data (Figure 2 ). The adjustment of the frequency is based on the current etCO 2 model. Conclusion Automation is a 'sine qua non' to achieve optimal patient individualized ventilation support. Our system is enabled to evaluate a therapeutic strategy and to base the settings of the ventilator on current trends/drifts observed in the data. Introduction There are very few data available from the Indian subcontinent regarding the use of noninvasive ventilation (NIV). We carried out this study to determine variables that could be used in the emergency room to predict survival in patients placed on NIV. Methods This was a prospective, observational cohort study carried out from 2001 to 2005 on all patients presenting with acute type II respiratory failure and meeting criteria for NIV use. NIV was started in the emergency room at settings that were titrated according to arterial blood gases. Univariate and multivariate regression analysis was used to determine the effect on survival. P < 0. 05 was considered statistically significant. The software used was SPSS 11.
section_name: Methods

section_name: P167 The impact of noninvasive versus invasive mechanical ventilatory support on survival in hematological patients

section_content: The total number of patients enrolled was 119; 52. 9% were males, 47. 1% were females. The mean age was 63. 3 years (±11. 9). The most common cause of respiratory failure was COPD in 91. 6%. A total of 56. 3% patients were stuporus at presentation, and 7. 5% fulfilled criteria for severe sepsis. There was no statistically significant difference between the baseline characteristics of the groups that survived or died. The overall survival rate for patients placed on NIV was 76. 5%, the intubation rate was 12. 6% and the length of hospitalization was 11. 4 days (±10. 9). Statistically significant improvements in pH and PaCO 2 occurred at 24 hours and 48 hours of NIV usage, compared with baseline (7. 28 vs 7. 37, P < 0. 001; 74. 2 vs 65. 4, P = 0. 003) (Figures 1 and 2 ). There was no significant change in PaO 2. The variables predicting survival were age (62. 1 ± 12. 5 years, 67. 8 ± 8. 7 years, P = 0. 025), serum creatinine (1. 1 ± 0. 5 mg/dl, 1. 7 ± 0. 8 mg/dl, P = 0. 002), pH at baseline (7. 31 ± 0. 09, 7. 25 ± 0. 9, P = 0. 005), HCO 3 at baseline (36. 1 ± 7. 5 mEq/l, 32. 4 ± 9. 3 mEq/l, P = 0. 032), pH at 48 hours (7. 39 ± 0. 07, 7. 33 ± 0. 06, P = 0. 002), and need for endotracheal intubation (10%, 21%, P < 0. 05). An RSBI <105 has been widely accepted by healthcare professionals as a criteria for weaning to extubation and has been integrated into most mechanical ventilation weaning protocols. We hypothesized that the converse of using the RSBI for weaning might be useful in predicting the need for noninvasive ventilation.
section_name: Results

section_content: Advancements in technology have made it easier to accurately attain bedside RSBI measurements. The purpose of this study was to ascertain a threshold value of RSBI that could predict the need for noninvasive ventilation (NIV) in patients presenting with acute respiratory distress to the critical care area (Cat 1) in the emergency department. Methods This was a blinded, observational cohort trial that was approved by the Henry Ford Hospital Institutional Review Board. Henry Ford Hospital is an urban, tertiary institution in Detroit, Michigan with an emergency department census of 95,000 patient visits per year. Inclusion criteria: patients > 18 years of age triaged to Cat 1 with acute respiratory distress and for whom the decision to intubate, use NIV or discharge the patient had not been decided. Exclusion criteria: immediate intubation, NIV, or discharge from Cat 1. Baseline demographics and vital signs were collected prior to the initiation of the trial (Figure 1 ). The CO2SMO Plus! with the ETCO 2 /flow sensor was used for obtaining bedside measurements. Patients would breathe through the ETCO 2 /flow sensor for 60 seconds with nose clips.
section_name: Conclusion

section_content: The threshold value for RSBI that discriminated best between no NIV and the need for NIV was determined in 61 patients. Thirty-five patients who did not require ventilatory support had a mean RSBI of 105, and 26 patients with NIV had a mean RSBI of 222 (P = 0. 0001). A receiver-operating-characteristic curve was constructed based upon the dataset in increments of 10 for the RSBI (Figure 2 ). An RSBI > 120 yielded a sensitivity of 0. 81 and a specificity of 0. 74 for determining the need for NIV. A likelihood ratio positive (LR+) of 3. 14 further illustrates the formidable predictive value of the 120 RSBI.
section_name: Results

section_content: A RSBI of 120 or greater, as reflected by f/VT ratio, may be a predictor of when NIV support should be considered. 

Further prospective randomized studies are needed to validate the value of 120.
section_name: Conclusion

section_content: Is threshold useful in accelerating weaning from mechanical ventilation? Background Reduction of time on the ventilator is a key concept to avoid complications. Recommendations include semirecumbent positioning (SRP) [1], low tidal volume ventilation (TV = 6 ml/kg) [2], prophylaxis for stress ulcer (SUP) [3], and deep vein thrombosis (DVTP) [4]. 1 ). On average, low tidal volume ventilation was adopted. DVTP and SUP were well implemented without training. There was no effect on frequency of pneumonia, ICU length of stay, or survival. Results Until the first attempt was made for weaning, all patients received assist-control ventilation because of haemodynamic instability. The following underlying conditions were present: chronic obstructive pulmonary disease in 67 patients, neuromuscular disorders in nine patients, acute lung injury as a result of surgery in 14 patients, asthma in six patients and miscellaneous causes in eight patients. The duration of mechanical ventilation before weaning was 2. 5 ± 0. 5 days in the SIMV+PSV group vs 2. 4 ± 0. 4 days in the ITSB group (P = 0. 02) and the duration of weaning was 6. 2 ± 0. 23 hours vs 8. 3 ± 0. 44 hours in the two groups, respectively (P < 0. 01). Patients who remained extubated for 48 hours were classified as having successful extubation -the rate of successful extubation in the first 24 hours of starting weaning was higher for the SIMV group (79. 2%) than in the ITSB group (64. 7%, P < 0. 01). The total duration of mechanical ventilation was 3. 3 ± 0. 3 days vs 5. 2 ± 1. 1 days and the ICU length of stay was 5. 6 ± 1 days vs 7. 5 ± 1. 7 days in the two groups, respectively (P < 0. 01). 

Conclusions The use of SIMV+PSV as a weaning method in the surgical ICU lead to shorter duration of weaning, a higher rate of successful extubation, a shorter duration of mechanical ventilation and less ICU stay than the use of ITSB.
section_name: P170

section_content: Hospital de Clinicas de Porto Alegre, Brazil Critical Care 2007, 11(Suppl 2):P173 (doi: 10. 1186/cc5333) Introduction Aging causes structural and functional modifications in the respiratory system. The evidence that these changes could impair weaning in elderly patients, until now, was not clear. We designed a protocol to study possible differences between an adult group (AG, up to 60 years) and an elderly group (EG, >60 years) in a daily screening trial. Methods One hundred and forty-four patients (79 EG and 65 AG) were studied. The primary outcome was weaning success (48 hours of spontaneous ventilation after extubation). The secondary outcome was differences in the conventional weaning predictors. Parameters studied included: respiratory rate (f), tidal volume (VT), frequency-tidal volume ratio (f/VT), gasometric and ventilatory parameters. The weaning method was a spontaneous breathing trial. Measurements were performed twice: just before the spontaneous breathing trial (T1) and 30 minutes after (T2). The S71 chi-square test, analysis of variance and t test were used in the analysis.
section_name: P173 Predicting successful weaning in a cohort of elderly patients C Corbellini, A Guntzel, C Trevisan, S Vieira

section_content: Weaning success was 86% both in EG and AG (P = 0. 989). There were no differences in gasometric and in ventilatory parameters between groups. Comparisons in TI and T2 in AG and EG are presented in Table 1. Sensitivities of f/VT in T1/T2 were: for EG, 94 (86-98)/96 (89-98); for AG, 95 (86-99)/100 (94. 8-100).
section_name: Results

section_content: The weaning success in our study is similar to that described in other trials. Older patients showed differences in f, VT and f/VT when compared with adults. However, there were no differences in weaning success.
section_name: Conclusion

section_name: P174 Heart rate variability during weaning from mechanical ventilation

section_content: During weaning from MV, cardiac patients showed higher RR and higher f/VT during TT when compared with PSV. Furthermore, there were significant changes in the RR and HR intervals in TT. However, we did not find significant changes comparing HRV in groups, perhaps because the frequency domain analysis had low power to verify those changes. 

Introduction Acute illness adversely affects a patient's circadian rhythms. Minimising the delayed restoration of these rhythms may have patient benefits. The aims of this study were to investigate the acute effects of exogenous melatonin on the rest-activity rhythms of patients recovering from critical illness, and furthermore to analyse the rhythms and relationship between plasma melatonin and cortisol levels. Methods A randomised controlled trial in 24 critically ill patients weaning from mechanical ventilation. Ethics committee approval was granted and all patients provided written consent. Twelve patients in each group received placebo or 10 mg exogenous melatonin at 21:00 hours for four nights. Twelve plasma samples were taken periodically from the first 18 of these patients over a 24-hour period. Actigraphy was used to monitor patient activity. Rhythm analysis of plasma levels and activity data used single cosinor analysis and nonparametric parameters, respectively. Results Both groups were well matched. There were no significant differences between the groups in any of the rest-activity measures, which were abnormal and comparable with those previously reported [1]. There was a weak inverse correlation between plasma melatonin and cortisol levels (r = -0. 22, P = 0. 015). Seven of 18 patients had a circadian rhythm of plasma cortisol levels, while only two patients had a normal acrophase. Four of the nine placebo patients had a circadian rhythm of melatonin, but only one of these had a normal amplitude and acrophase. The plasma melatonin 24-hour area under the curve was significantly reduced compared with healthy elderly people (128. 4 (112. 6; 217. 0) versus 464. 5 (372. 5; 594. 0), P < 0. 001). A moderate inverse relationship existed between the percentage plasma cortisol rhythm and patient intradaily variability (r = -0. 70, P < 0. 002). Conclusions Acute administration of exogenous melatonin did not result in significant differences in rest-activity rhythms between the groups. Most patients lacked circadian rhythms of plasma melatonin and cortisol levels, which were no longer phase locked. for tracheostomy and duration of stay were collected. The patients were then subdivided into unsuccessful and successful weaning attempts based upon whether they required subsequent ventilatory support during the first 48 hours after their weaning ended. The two groups were then analysed to identify the characteristics of the patients where a successful SC wean was achieved. 

Results After excluding patients whose weaning was interrupted by transfer or a decision to withdraw treatment, we had 89 weaning attempts to analyse. These represented 43 successful (S) and 46 unsuccessful (US) weans. Comparison of mean ± SD ages (S 61 ± 14. 3 years, US 57. 3 ± 16. 1 years, P = 0. 28) and APACHE scores (S 16. 2 ± 4. 9, US 17. 7 ± 6. 5, P = 0. 23) for the two groups showed no major differences. Logistic regression demonstrated that the worst FiO 2 prior to weaning and the duration of ventilation prior to weaning were both significantly associated with an unsuccessful SC weaning attempt (P = 0. 002 and P = 0. 005, respectively). ROC curve analysis suggested patients with an FiO 2 below 0. 47 and a duration of ventilation prior to weaning of below 43 hours were more likely to be successfully weaned. 

Conclusions SC proved most successful in those patients who had a lower worst FiO 2 prior to weaning and a lower duration of ventilation prior to commencing weaning.
section_name: Conclusion

section_content: Assessing the impact of introducing the 'ventilator bundle' on outcomes for mechanically ventilated patients Background The concept of bundles was developed by the Institute for Healthcare Improvement. Individual bundle elements are built on evidence-based practice, and the bundle concept is that when these elements are executed together they produce better outcomes than in isolation. There is, however, limited evidence linking the use of bundles to demonstrable changes in patient outcomes. As a preliminary analysis to inform a multicentre evaluation, we explored the effect of the introduction of the 'ventilator bundle' on the outcomes for mechanically ventilated patients in a single critical care unit. Methods Data were extracted for mechanically ventilated admissions from a single unit participating in the Case Mix Programme that was an early adopter of the ventilator bundle. A risk prediction model was developed using data from admissions during the 3. 5 years prior to the introduction of the bundle and applied to admissions during the 3 years since introduction to estimate the cumulative excess mortality (observed minus expected deaths). Results There were 762 ventilated admissions prior to the introduction of the bundle and 618 since. The cumulative excess mortality plot suggested a reduction in mortality after introduction of the bundle (Figure 1 ) but this was not statistically significant (relative risk reduction 10. 9%, 95% confidence interval -10. 2% to 31. 8%).
section_name: P177

section_content: The results suggest that it will be beneficial to carry out a multicentre evaluation of the ventilator bundle in Case Mix Programme units, and will inform the design of this study.
section_name: Interpretation

section_content: Hemodynamic changes due to expiratory positive airway pressure by facial mask in the postoperative period of cardiac surgery S Vieira 1, A Sena 2, S Pinto-Ribeiro
section_name: P178

section_content: Results Twenty-eight patients were studied (22 men, mean age 68 ± 11 years). The most common surgery was myocardial revascularization (n = 17). EPAP was well tolerated in the patients studied. Comparing rest and EPAP periods, increases were observed in: PCWP (11. 9 ± 3. 8 to 17. 1 ± 4. 9 mmHg, P < 0. 001); CVP (8. 7 ± 4. 1 to 10. 9 ± 4. 3 mmHg, P = 0. 014); MPAP (21. 5 ± 4. 2 to 26. 5 ± 5. 8 mmHg, P < 0. 001); MAP (76 ± 10 to 80 ± 10 mmHg, P < 0. 035). All other variables did not show significant changes. These results were observed in the total group and when divided concerning ejection fraction >50% or <50%. 

Conclusions EPAP was well tolerated in this group of stable patients after cardiac surgery and the hemodynamic changes due to its use were an increase in the measurement of right and left filling pressures as well as a small increase in arterial pressure.
section_name: S73

section_content: Predicting successful nasal continuous positive airway pressure treatment in newborn infants: a multivariate analysis J Swietlinski 1, T Bachman 2, K Bober Background The use of nasal continuous positive airway pressure (nCPAP) in newborn infants is common, especially for weaning after mechanical ventilation. We have reported on the successful transition to the use of the infant flow method as a standard of practice in Poland. 

Objective The authors present results of multivariate logistic regression (MLR) analysis of 481 newborns treated with the infant flow method in an effort to improve related clinical guidance. Methods We collected data on the baseline demographic, physiological characteristics and outcomes of 1,299 newborns treated with nCPAP in 57 neonatal ICUs in Poland over a 2-year period. We conducted a stepwise MLR of 481 newborns with the two most common indications for use. We evaluated three outcomes: need for intubation in newborns treated electively with nCPAP (RDS), weaning failure requiring reintubation in the mechanically ventilated newborns (weaning), and bad outcome.
section_name: P179

section_content: In the RDS group of patients we found that nCPAP failure was highly significantly related to estimated gestational age and clinical risk index for babies (CRIB). While in our population less mature RDS newborns were only slightly less likely to avoid intubation, the MLR model showed that, controlling for initial CRIB, they were less than one-half as likely to avoid intubation. Failure of nCPAP in weaning was highly significantly related to only pH, prior to beginning nCPAP. Bad outcomes were highly related to estimated gestational age and CRIB in the RDS group, but not the weaning population. Conclusions We believe that understanding the risk of both nCPAP failure and also bad outcomes for a specific patient will enhance clinical decision-making. That is, for patients with the highest risk of poor outcome or nCPAP failure, more aggressive use of intubation and surfactant might be warranted. Likewise, such aggressive therapy might also be avoided for those with a seemingly low chance of poor outcome. 

Introduction Advocates of airway pressure release ventilation (APRV) suggest that this mode is lung-protective for patients with ALI/ARDS, while providing additional benefits of spontaneous breathing, including improved haemodynamics, decreased need for sedation, and better patient comfort. However, there are few available data on the clinical experience with APRV. Methods We conducted a retrospective audit of consecutive patients receiving APRV from January 2004 to August 2006 in three academic ICUs in Toronto. APRV was initiated at the discretion of the attending physician; a protocol guiding the implementation of APRV was introduced in July 2006. We recorded data describing: baseline characteristics; how APRV was used; its potential ramifications including oxygenation and sedation/analgesia doses; and outcomes.
section_name: Results

section_content: Thirty patients, all with ALI/ARDS, received 39 trials of APRV during the study period -median age 52 years, 60% male, 50% pulmonary ALI risk factor, median APACHE II score 28. They had ALI for a median of 4. 5 days with a median 135 hours of CMV before APRV. They received a median of 38 hours APRV. By 12 hours, oxygenation improved significantly (P/F ratio from 103 to 159, P < 0. 01), with a concomitant decrease in FiO2 requirements (from 0. 70 to 0. 50, P < 0. 0006). At 72 hours, the median P/F ratio had improved to 196 on a median FiO 2 of 0. 40 (both P < 0. 01). Administration and dosages of sedatives (midazolam equivalents, propofol) and analgesics (morphine equivalents) did not change significantly over the period from 24 hours before to 24 hours after APRV initiation. There were two episodes of barotrauma during APRV; neither required therapeutic drainage. The 30-day mortality was 13/30 (43%), most commonly due to multiorgan failure and withdrawal of life-support. Conclusions In our patients APRV use appeared safe, led to improved oxygenation, but did not change needs for sedation/analgesia. Future studies are needed to determine the optimal timing and methods for ARPV use; these should be followed by randomized trials to confirm safety and document the effects of APRV on patient-centered outcomes.
section_name: Results

section_content: Introduction Recent data suggest that dynamic measurements of respiratory mechanics should be preferred to static measurement for lung protection [1]. The aim of this study was to analyze similarities and differences between dynamic methods: the stress index (SI) [2] and SLICE [3]. 

Introduction A reduced content of biophysically active large surfactant aggregates is a common finding in acute inflammatory lung disease. Cyclic surface area changes and a carboxylesterase activity (surfactant convertase) are thought to mediate this subtype conversion. However, data concerning regulation of surfactant convertase are scarce. We therefore investigated the expression and activity of lung surfactant convertase and HMSE-1, a potential macrophage-derived human convertase, under normal and acute inflammatory conditions. Methods Convertase activity in lavage fluid (BALF) was assessed using the in vitro cycling assay. The relative large surfactant aggregate content was determined by phospholipid quantification in the pellet following centrifugation at 48,000 x g. Esterase activity was assessed by means of a chromogenic substrate assay. Expression of both convertase and HMSE upon LPS challenge was assessed by real-time (TaqMan) PCR in murine alveolar macrophages, murine primary type II cells, and the human monocytic cell line U937, respectively. Results Lavage fluid from ARDS patients displayed an increased esterase activity when compared with BALF from healthy controls. 

In addition, a pronounced large to small aggregate conversion was observed for BALF from LPS-challenged mice or BALF from ARDS patients. Incubation with LPS resulted in a significant increase in convertase gene expression in primary mouse type II cells as well as in HMSE-1 gene expression in U937 cells and monocytes from peripheral blood. No convertase expression was found in cultured murine alveolar macrophages. Conclusions An increased convertase activity was found under acute inflammatory conditions of the alveolar compartment, and type II cells seem to be a relevant source of this increased convertase activity. However, leakage of esterase activity from the vascular space and other inflammatory cells cannot be ruled out.
section_name: P181 Importance of nonlinearities to quantify mechanical pulmonary stress under dynamic conditions: stress index and SLICE method

section_name: P183 Transgenic mice expressing a surfactant protein B-urokinase fusion protein in the distal respiratory epithelium are protected against acute lung injury and postinflammatory fibrosis

section_content: The results of the ARDS Network trial [1] demonstrated a significant reduction of mortality by using a mechanical ventilation protocol with tidal volumes (VT) of 6 ml/kg predicated body weight. Additionally, a computer-driven weaning protocol was successfully performed and a reduction of mechanical ventilation duration could be demonstrated [2]. The implementation of the ARDS Network protocol in routine ICU practice remains modest [3]. A possible reason is the increased organisational and temporal burden. An automated execution of the protocol would help to propagate its day-to-day use. To test the ability to automate such a complex protocol, we designed a pilot study in porcine acute lung injury using an experimental medical expert system capable of continuously controlling respiratory parameters and global as well as regional ventilation with electrical impedance tomography (EIT). Methods After induction of saline lavage-induced lung injury in pigs (n = 3), automated mechanical ventilation was initiated. The medical expert system used a closed-loop fuzzy controller with a rule base of if/then rules based on the ARDS Network protocol reference card. The protocol's algorithmic rules and therapeutic goals (oxygenation, pH, I:E, VT) were continuously controlled and ventilatory settings electronically adjusted accordingly. The medical attendant personnel was constantly informed with status messages about the decisions made. During the trial, all measurements were made using an online blood gas monitor (TrendCare Satellite; Diametrics Medical Inc., UK), a monitor for hemodynamic parameters (Sirecust 1281; Siemens, Germany), a capnograph (CO 2 SMO+; Respironics, Inc., USA), and an EIT prototype system (EIT Evaluation Kit; Draeger Medical, Germany). Subjects were ventilated for between 40 and 90 minutes.
section_name: Introduction

section_content: The computer-driven ventilator settings could stabilise the ventilation of the lung-injured subject in the predefined thresholds. 

Compared with the beginning of the study, a reduction in ventilation pressure and PaCO 2 could be observed. Despite the initial low PaO 2 /FiO 2 ratio (<200 mmHg) of the subjects, FiO 2 could be decreased by the system in the given time without penetrating the thresholds for oxygenation. Conclusion Robust execution of an automated ARDS Network protocol with an electronically controlled ventilator is possible and leads to pulmonary stabilisation. Further trials have to be undertaken before this successful approach can be realised in ARDS patients. there were no differences in PEEP values along the study. Initial values of PaCO 2 were 47 (41-69) mmHg and there were no significant differences along the study period. After 24 hours of PPV, the LIS was significantly decreased in comparison with the supine value before PPV: 3 (2. 25-2. 7) vs 2. 5 (2. 25-2. 75), P = 0. 001. There were no significant complications. Conclusions PPV had a positive effect on gas exchange even after 6 hours. This effect lasts through the PPV period. Because of its effect on the LIS, a duration of 24 hours for continuous PPV could be useful in this patient setting. 

Introduction There is great controversy concerning protective ventilation in ARDS. Recruitment maneuvers and PEEP titration sufficient to avoid collapse and tidal recruitment are the major goals of the maximal recruitment strategy (MRS). Objectives To describe clinical and demographic data. To evaluate the incidence of complications related to transportation and to the MRS. Methods Forty-three patients with ARDS were transported to CT and submitted to the MRS, which consisted of 2-minute steps of ventilation with a fixed PCV = 15 cmH 2 O and progressive PEEP levels (10-45-25-10 cmH 2 O), RR = 10, I:E = 1:1, and FiO 2 = 1. 0. Opening (recruitment) and closing (PEEP titration) pressures were determined according to the least amount of collapse observed at the CT, and were used to ventilate the patients afterwards. 

Results Clinical data are presented in Table 1. There were no complications due to transportation and one patient developed pneumomediatinum after the protocol. Conclusions MRS was well tolerated in this series of patients, rendered the gas distribution through the lung more homogeneous, improved gas exchange and was related to low mortality. A RCT to test the MRS is necessary. 

Introduction High tidal volume mechanical ventilation (HTVMV) leads to pulmonary edema from increased endothelial permeability. 

The lungs show evidence of inflammation with endothelial adhesion molecule expression, infiltrates of white blood cells and cytokine production. In order to understand the molecular mechanisms responsible for the pathogenesis of ventilator injury, mouse models are beneficial but technically difficult due to the small size of the animal. To study the time course of lung edema formation we compared lung elastance measured by forced oscillations with invasive methods of lung edema detection (for example, wet-dry weight ratio and histology). Methods C57Black6 mice were anesthetized with i. p. sodium pentothal and paralyzed with succinylcholine. A tracheostomy was performed and the animals were connected to a Flexivent ventilator (Sqirec). The HTVMV group received a tidal volume of 25 ml/kg and 33 breaths/minute for 4 hours. The control group received 7 ml/kg at 120 breaths/minute. Temperature was kept at 36-37°C with the aid of a heated pad. The heart rate was monitored with surface EKG electrodes. Lung elastance and tissue energy dissipation were measured every 30 minutes using the forced oscillation technique. At the end of the experiment a sternotomy was performed. A ligature was placed around the right hilum and the right lung was cut, briefly rinsed in PBS, blotted dry and weighed. The dry weight was obtained following desiccation at 60°C for 48 hours. The left lung was inflated with 500 µl formalin injected slowly into the tracheal canula and embedded in paraffin. Paraffin blocks were sectioned with a microtome at 5 µm thickness and stained with hematoxylin-eosin.
section_name: Results

section_content: The wet-to-dry weight ratios rose from 4. 82 ± 0. 16 in control animals to 6. 34 ± 0. 83 in the HTVMV group (P < 0. 05, n = 4). Light microscopic examination of histologic sections showed mononuclear white cell infiltrates around small arteries and within the alveolar walls of mice in the HTVMV group but not in control mice. Elastance rose nonsignificantly during the HTVMV protocol. Conclusions In this in vivo mouse model, high tidal volume mechanical ventilation caused pulmonary edema and lung tissue infiltration with white blood cells. However, measurements of lung mechanics showed minimal changes during the course of the experiment, indicating that they are less useful in detecting early edema. The utility of this method is limited due to high efforts needed to evaluate sequences of images with respect to alveolar geometry. The evaluation -done by hand -is time consuming, places a high cognitive load on the examiner and is error prone. Reproducibility of results is low. This project aims to establish a computer-assisted tool that provides semi-automatic evaluation of video sequences acquired with alveolar endoscopy. Methods We developed a computer program based on Matlab (Mathworks, Natick, MA, USA), which analyses video sequences acquired with an alveolar endoscope (Schölly, Denzlingen, Germany) [2]. The user has to provide a pointer to the alveoli that shall be traced and whose changes in size and shape are to be determined. Filters, smoothing splines and expectation-driven fine tuning is performed to achieve robust and predictable results of the intratidal change in alveolar geometry.
section_name: Results

section_content: Results Animal studies related to alveolar mechanics during artificial ventilation were conducted. Figure 1a shows a plot of a frame taken from a video obtained during an experiment performed on a healthy anesthetized rat. Overlaid circles indicate identified boundaries of a selected alveolus. Figure 1b presents a trace of alveolar diameter during a tidal breath. Evaluation of successive frames allows one to compensate for motion artifacts and to analyze the intratidal changes in alveolar geometry. Conclusion Given a synchronization with respiratory data, this tool will allow one to quantify pressure-related changes of alveolar size. 

Thus it will allow one to monitor the alveolar distension in a variety of animal models (for example, lavage-induced ARDS) and to correlate these findings, for example, with outcome. 

Introduction Alveolar recruitment and maintenance of lung volume are important goals in the treatment of acute lung injury (ALI) and essential for improving oxygenation. The most usual employed strategy to achieve this goal is the use of positive end-expiratory pressure (PEEP). Recruitment and collapse are highly dynamic phenomena that are difficult to monitor. Dynamic effects of regional ventilation can be monitored by electrical impedance tomography (EIT) at the bedside [1]. We investigated the ability of EIT for providing a useful tool to detect dynamic changes of regional breath by breath recruitment at the bedside during an incremental and decremental PEEP trial in experimental lung injury. In addition, we analyzed pressure-volume (P-V) curves computed by EIT data.
section_name: P190

section_content: of ventilator settings and respiratory mechanics is crucial for further developments of protective lung ventilation. Up to now, the nonlinearity of compliance has mainly been the focus of interest. 

We hypothesized that airway resistance also changes intratidally. Therefore, this study was performed to analyze the dependence of resistance on tidal gas volume. Methods After induction of anesthesia and tracheotomy, the lungs of 14 surfactant-depleted piglets were ventilated at zero endexpiratory pressure with three different tidal volumes (8, 12, 16 ml/kg) in a randomized order. In addition, baseline measurements (12 ml/kg) were performed before saline lavage. Before any change of the ventilator settings a recruitment maneuver was performed. The nonlinear intratidal airway resistance was analyzed using the SLICE method [1]. 

Results Figure 1 shows the intratidal resistance before lavage (grey) and after surfactant depletion (black) plotted against the alveolar pressure. Each curve in the diagram represents the intratidal course of resistance for one ventilator setting. Resistance is increased after surfactant depletion and is intratidally declining before and after lavage.
section_name: S79

section_content: The analysis of resistance shows a dependence on intratidal volume. The nonlinear course of intratidal resistance can be interpreted as a volume-related caliber effect leading to an increase of cross-sectional area of the large and small airways. As shown in Figure 1, ARM induced a significant increase in the peak plasma level concentration of all cytokines that returned to basal levels within 12 hours. No adverse effects were observed during and after ARM. Conclusions Despite beneficial effects in reversing atelectasis, ARM-induced lung stretching was associated with an inflammatory response in healthy volunteers.
section_name: Conclusion

section_content: Introduction Recruitment/derecruitment (R/D) seems to play an important role in the development of VILI [1]. Many clinicians base their determination of PEEP settings during mechanical ventilation of ARDS/ALI patients on an estimate of alveolar recruitability [2]. This project aims to establish an online tool that provides estimates of R/D in patients at the bedside. Results FRC increase in group A is statistically significant (W) (step 1: 1,525 ± 360 ml; step 2: 1,937 ± 583 ml, P < 0. 05 vs step 1; step 3: 2,592 ± 659 ml, P < 0. 05 vs step 2 and P < 0. 01 vs step 1) while the FRC increase in group B is not significant (step 1: 1,697 ± 210 ml; step 2: 1,757 ± 367 ml; step 3: 1,982 ± 365 ml); the FRC of group A is statistically higher than the FRC of group B in step 2 (P < 0. 05 MW) and in step 3 (P < 0. 01 MW). The ratio increase in group A is statistically significant (W) (step 1: 256 ± 133; step 2: 407 ± 187, P < 0. 01 vs step 1; step 3: 379 ± 169, P < 0. 05 vs step 1) while the ratio increase in group B is not significant (step 1: 194 ± 50; step 2: 253 ± 83; step 3: 276 ± 73); the ratio of group A is statistically higher than the ratio of group B in step 2 (P < 0. 01 MW) and in step 3 (P < 0. 05 MW). The C stat increase in both groups is not significant, but in group A C stat is statistically higher than C stat of group B in every step (P < 0. 05 MW) (step 1: 38 ± 2 ml/cmH 2 O for group A vs 28 ± 7 ml/cmH 2 O for group B; step 2: 44 ± 6 ml/cmH 2 O vs 36 ± 8 ml/cmH 2 O; step 3: 47 ± 5 ml/cmH 2 O vs 36 ± 8 ml/cmH 2 O). Conclusion With the limit of low sample size, these preliminary data suggest that the FRC evaluation system is a good parameter to optimize pulmonary recruitment and seems to be in a position to overcome the C stat limit for the evaluation of pulmonary recruitable parenchyma. Conclusion Although we believed that the unit's approach to HFOV was one of 'treatment' rather than 'rescue', our results suggest we are still using HFOV in a 'rescue' mode. While our results support the findings of other studies that earlier initiation of HFOV shows a trend towards improved outcome in adult patients with ARDS, further studies are still required to identify appropriate parameters for selecting patients in a timely manner who may benefit from HFOV. However, progressive acidosis in ARDS appears to be a relatively more important predictive criterion than parameters of failing oxygenation and ventilation.
section_name: P194 Noninvasive alveolar recruitment maneuver induces cytokine release in healthy volunteers

section_name: Methods

section_content: Inadvertent endobronchial intubation and one-lung ventilation (OLV) with a standard endotracheal tube may lead to serious complications, such as a nonventilated lung, pneumothorax and hypoxemia. Auscultation of breath sounds was found to be
section_name: Introduction

section_content: inaccurate for the detection of OLV with a high margin, up to 60% error [1]. Vibration response imaging (VRI) is a novel technology that measures vibration energy from the lungs and displays regional intensity in both visual and graphic format. The time from the start of the procedure to display takes less than 1. 5 minutes. 

We investigated the effectiveness of VRI to detect OLV using a double-lumen endotracheal tube in lung surgery patients. Methods Double-lumen tubes were placed at the time of surgery. 

Tracheal and endobronchial lumens were alternately clamped to produce unilateral lung ventilation of the right and left lungs. VRI was performed after each occlusion. Two images were excluded a priori (prior to analysis) due to technical failure (external artifact).
section_name: S83

section_content: The right and left lung distribution of vibration intensity is shown in Figure 1. The mean percentage change of vibration intensity clearly demonstrates the increased vibration in ventilated lungs (89. 1 ± 5. 47% vs 10. 9 ± 5. 4%, P < 0. 05) (Figure 2 ). Conclusions Auscultation is insensitive to endobronchial intubation and chest radiography may not be immediately available. VRI offers the potential to rapidly and noninvasively determine endobronchial intubation. Currently VRI is performed in the sitting position, but the capability of supine imaging will soon be available.
section_name: Results

section_content: In the mechanically ventilated patient, when there is minimal flow, the vibration was at its lowest. When flow begins at the ventilator, the vibration measured over the lungs increases and when the flow stops, the vibration decreases. An inspiratory hold was performed to separate inspiratory from expiratory vibrations (Figure 1 ). As the subject takes increasing tidal volumes, the vibration during the breath cycle increases linearly. A sample subject is shown in Figure 2 (R 2 = 0. 81). Conclusion Vibration measured using VRI correlates with lung airflow. Given the difficulty in assessing airflow in the lungs, measuring lung vibration could potentially serve as a surrogate for regional lung airflow.
section_name: Results

section_content: The Gliding-SLICE method: an enhanced tool for estimation of intratidal respiratory mechanics Introduction Focusing on lung-protective ventilation, the analysis of nonlinear dynamic respiratory mechanics appears crucial. Based on the SLICE method we developed the Gliding-SLICE method as a tool to determine respiratory system mechanics. This tool was tested in a nonlinear water-filled two-chamber lung model. Methods The classic SLICE method [1] determines parameters of the respiratory system for abutted volume ranges. The Gliding-SLICE method enhances this method by moving a window of analysis along the volume axis. This way, a quasi-continual course of intratidal mechanics can be determined. To test the new method we build up a physical model that consists of two connected chambers filled with water. During inspiration water is displaced from one chamber to the other resulting in a counter pressure. 

Using wedges of certain shapes we simulated volume-dependent nonlinear compliances. 

Results Using the Gliding-SLICE method we determined a nonlinear course of compliance in a patient (Figure 1 ) and in model data (Figure 2 ).
section_name: P204

section_content: The Gliding-SLICE method allows one to calculate mechanical parameters of the respiratory system quasi-continually. This allows a more intuitive interpretation of data. The method is not limited to principle constrictions but can be enhanced by ventilatory maneuvers; for example, for separated view on inspiratory and expiratory respiratory mechanics. Methods The percentage of V non (%V non ) relative to the total lung volume was quantified in CT-image series (n = 21) of sheep with gross anesthesia-induced atelectasis. This was performed for different combinations of number and anatomical location of CT slices and the results were compared with the %V non of the entire lung (lung). The combinations were: one juxtadiaphragmatic slice (juxta), three apical, hiliar and juxtadiaphragmatic slices (3old), and three consecutive juxtadiaphragmatic slices (3new). The correlation between %V non and the arterial oxygen partial pressure (PaO 2 ) was examined for all combinations. The PaO 2 was measured at the time of the CT and transformed logarithmically (lnPaO 2 ) to linearize the relation between PaO 2 and %V non. Linear regression and Bland-Altman plots were used for statistical analysis.
section_name: Conclusion

section_content: The R-squared (R 2 ) values for the correlation between lnPaO 2 and %V non of lung and the slice combinations juxta, 3new and 3old were 0. 61, 0. 60, 0. 57 and 0. 55, respectively. The %V non of lung correlated best with the %V non of slice combinations juxta and 3new (R 2 = 0. 96 and 0. 95, respectively). Comparison of these slice combinations with lung also resulted in the least bias in the Bland-Altman analyses (6. 3 and 5. 9%, respectively). R 2 for the correlation between lung and 3old was 0. 93, and the bias for lung vs 3old in the Bland-Altman analysis was 6. 8%. Conclusion Depending on the precision required, the use of single juxtadiaphragmatic CT slices can help to speed up the analysis process and thereby propel the clinical implementation of CTderived information. Our data suggest that juxtadiaphragmatic slices may be better suited than the 'traditional' combination of apical, hiliar and juxtadiaphragmatic slices.
section_name: Results

section_content: Pulmonary expansion and disobstruction maneuver with a closed system in patients with acute lung injury and acute distress syndrome, and its effect on gas exchange, drug poisoning n = 1, pulmonary edema n = 1) with the Bonfils intubation fiberscope, the use of which was either planned (n = 13) or unplanned (n = 2). All intubations were successful in the first attempt, even in two cardiac arrest victims who had an unexpected difficult airway (Cormack&Lehane grade IV under direct laryngoscopy). In those patients with multiple injuries the cervical immobilization collar did not need to be unfastened or removed for endotracheal intubation. Sufficient retropharyngeal space -which is mandatory for sufficient use of the Bonfils -was created by a digital jaw thrust maneuver in the first three patients. Using a standard Mackintosh laryngoscope blade significantly enhanced ease of insertion of the Bonfils fiberscope and visualization of the glottic aperture, thereby decreasing the procedure time from 35-40 seconds to 20-25 seconds. Conclusion Despite this first promising series of in-the-field use, physicians and paramedics should familiarize themselves with the Bonfils device under optimal clinical conditions before using it under emergency or prehospital conditions. In our experience, the learning curve with the Bonfils device is steep, and 10 intubations supervised by an instructor usually prove effective for achieving sufficient skills to use the Bonfils on one's own and under less optimal conditions. In summary, we believe that the Bonfils fiberscope will prove its value as an additional airway management device in both, emergency and prehospital settings. Acknowledgement The Bonfils intubation fiberscope was generously provided by Karl Storz GmbH, Tuttlingen, Germany.
section_name: P207

section_content: Airway equipment on the intensive care unit for management of the unanticipated difficult intubation
section_name: P212

section_content: The number of unsuccessful placement attempts was none in the UBBR group (0/10) and one in the CBBR group (1/10), two in the UBBL group (2/10) and five in the CBBL group (5/10). A fiberoptic aided technique should be more appropriate for the leftsided blocker in both groups. There was no statistical difference in bronchial blocker malpositions, the lung to collapse and the number of complications among the two groups. Furthermore, for elective thoracic surgical cases, once the lung was isolated, the management seemed to be similar for both groups. Discussion This study demonstrates that the wire-guided bronchial blocker (Uniblocker™) provides a high torque control and can be easily manipulated into the desired site of the lungs. In conclusion, our study shows that the Uniblocker™ is more useful than the Coopdech bronchial blocker tube. Results Conventional HVLP cuffs do not prevent leakage of fluid past the cuff, hence the negative slope on the graphs. The LoTrach cuff does not leak and therefore the line is horizontal (see Figure 1 ). The clinical study shows that both the LoTrach and Portex cuffs demonstrate a gross air leak at equal and acceptable tracheal wall pressures at 33. 4 and 29. 7 cmH 2 O, respectively (see Table 1 ). Methods We reviewed the medical records of 20 patients admitted to a regional burn center requiring tracheostomy for prolonged mechanical ventilation. The procedure took place in the OR if burn excision was planned; otherwise it was performed at the bedside. The Blue Rhino tracheostomy kit was used for all PT. 

Major differences from other approaches included dissecting down to the pretracheal fascia, allowing the trachea to be seen and palpated; bleeding was controlled using an electrocautery, and blood vessels were retracted from the field or ligated. The trachea was palpated as the endotracheal tube was withdrawn into the proximal trachea and a flexible bronchoscope was used only to confirm the proper placement of the guidewire. Proper placement of the tracheal tube was confirmed by capnography. In patients with a deep trachea due to severe neck swelling, a proximal-long tracheostomy tube was substituted for the standard one. In the event that the airway or ventilation became compromised, this technique could be converted rapidly to an open procedure.
section_name: Results

section_content: Of 350 patients admitted to the burn center from July 2005 to December 2006, 20 (6%) required a tracheostomy. Eighteen were performed percutaneously, 13 at the bedside. The total burn surface area averaged 46% (range 2-95%). PT were performed within an average of 10 days from admission (range 0-32 days). Overall mortality in the tracheostomy group was 35%. There were no short-term complications associated with this method. Conclusion PT can be performed safely in severely burned patients using a semi-open percutaneous technique. Exposing the trachea and palpating the trachea avoids the risk of losing the airway and permits immediate access to the trachea in the event of an untoward loss of the airway. We believe that this method is safer than the more commonly used technique requiring bronchoscopic visualization. Introduction A retrospective analysis of a year cohort of tracheostomies discharged from intensive care in a specialist cardiothoracic centre was undertaken to analyse whether facilitated outreach-led discharge was safe. 

Methods A retrospective analysis of the ICU database was undertaken to identify all patients who had a tracheostomy (percutaneous or surgical) inserted in the ICU, and a chart review of patients discharged from the ICU with a tracheostomy in situ was performed. The following variables were collected: patient demographics; diagnosis; number of days of tracheostomy in situ; number of days on noninvasive ventilation (CPAP); and tracheostomy-related complications. A review of the risk management database was performed to identify any tracheostomy-related reported adverse events. Results One hundred and eight tracheostomies were performed in intensive care in the 2-year period. Sixty-two patients were discharged with tracheostomy in situ and were reviewed by the outreach team for a cumulative total of 710 days until decannulation. There were 383 days whereby patients with a tracheostomy in situ had been noninvasively ventilated. There were three reported critical events relating to tracheostomy and no deaths. Conclusion More than 60% of patients who had a tracheostomy inserted are discharged from critical care with a tracheostomy in situ. With the support of the outreach team these patients were successfully managed in Level 2 and Level 1 areas. This reduced the requirement for critical care (Level 3) bed-days. There was a low rate of complications. We concluded that outreach services can facilitate early and safe discharge of tracheostomy patients from critical care.
section_name: Results

section_content: A Pirogov 1, M Croitoru 2, R Badaev
section_name: P218 Prevention of airway control loss during percutaneous tracheostomy

section_content: The data collection showed: an increase in CI (baseline to standard therapy) of 2. 6 ± 0. 51 (P < 0. 001), and standard therapy to LS of 2. 93 ± 0. 67 (P < 0. 003) that seem to be additive. Significant increase in EF was noted in comparison with standard therapy (29. 88 ± 6. 15, P < 0. 035) and after LS therapy (38. 44 ± 6. 56, P < 0. 001) (Figure 1 ). To find differences between baseline and pharmacological therapy changes at 24, 48 and 72 hours a t test was performed.
section_name: Results

section_content: We found an additive effect of dobutamine, enoximone and LS that theoretically can be explained by the We analyze the data of 18 patients receiving levosimendan for myocardial depression due to severe sepsis and compare them with our historical data in the previous year of the same group of patients regarding mortality. All those patients were included in the study who had a pulmonary artery catheter (PAC) and who after initial resuscitation (early goal-directed therapy (EGDT)) did not respond to treatment and their cardiac index (CI) was <2. 2. Each patient than received an infusion of levosimendan at 0. 1 µg/kg/min without a loading dose. Hemodynamic parameters such as the CI, mixed venous saturation (SvO 2 ) and mean arterial pressure (MAP) were recorded at 0, 12, 24 and 48 hours. Noradrenaline was used to maintain a MAP above 65 mmHg. Patients were followed for 30 days to document the 7th-day and 30th-day mortality. SPSS 11 was used for statistical analysis. The Student t test was used as a test of significance.
section_name: Conclusion

section_content: The average age was 67. 6 ± 10. 39 years and the APACHE II score was 26. 33 ± 2. 37. Patients were divided into three subgroups: survivors, 7th-day and 30th-day mortality groups. 

There was no significant difference in these subgroups regarding age and APACHE II score. Levosimendan group 7th-day and 30thday mortality was 33% and 66% as compared with historical data of 37% and 71%, respectively. The change in CI in the survivor group was significant (P = 0. 021), from 2. 11 ± 0. 17 to 3. 8 ± 0. 28, while in the 7th-day and 30th-day mortality groups it was insignificant. SvO 2 increased in the survivor and 30th-day mortality groups significantly (P = 0. 011 and P = 0. 035, respectively). It did not show any significant improvement in the other group. MAP also showed significant improvement in the survivor group (P = 0. 026) and insignificant in others.
section_name: Results

section_content: It is evident from our study that levosimendan improves hemodynamic response in septic patients. Although it improves the mortality, we cannot say with full confidence that these improved hemodynamic parameters are responsible. Randomised control trials are needed to answer this question, which are underway.
section_name: Conclusion

section_content: The elderly acute coronary syndrome patient: a neglected population? During the follow-up, 43 patients developed events, most of them (n = 28) consisting of death (23 by cardiac death). However, most of these events occurred in the first month after the admission, the mortality between 1 month and 3 years being low (Figure 1 ). Conclusion Our data show that the octogenarian patients with STEMI treated by primary PCA developed a very high mortality. However, this mortality especially concentrates in the first month after the procedure, being low between 1 month and 3 years.
section_name: P227

section_content: Outcome in myocardial infarction is related to the morphologic pattern of ST elevation R García-Borbolla 1, I Nuñez Gil 2, J García Rubira Results Table 1 summarises clinical features according to SBT. After adjustment of potentially confounding variables, SBT was the variable associated with less ST-segment resolution (HR 1. 772, 95% CI 1. 46-4. 15, P = 0. 02). Results ST elevation with distortion of the terminal portion of QRS were present at initial ECG in 55 patients (23%). This group had a lower incidence of Rentrop grade 2/3 than group 2 (P = 0. 006, Figure 1 ). Moreover, group 1 had higher enzyme release, worse maximal Killip class and more frequently the combined variable death/shock. Group 1 more often had proximal occlusion of the infarction-related artery and nonreflow. Multivariate analysis found ECG to be an independent predictor of outcome. Objective To determine the association between hemoglobin concentrations on admission and inhospital 30-day cardiac mortality and complications among patients with acute myocardial infarction during their hospital course. Methods We conducted a retrospective study of data on 660 Chinese patients who were hospitalized with acute myocardial infarction. Patients were categorized according to the hemoglobin concentration on admission, and data were evaluated to determine whether there was an association between the hemoglobin concentrations on admission and inhospital 30-day mortality and complications. Complications were defined as cardiogenic shock, congestive heart failure, arrhythmia, ventricular tachycardia or fibrillation and pneumonia.
section_name: P229

section_content: Available online http://ccforum. com/supplements/11/S2
section_name: Conclusion

section_content: Results Patients with hemoglobin values between 140 and 159 g/l were used as the reference; cardiovascular mortality increased as hemoglobin levels fell below 140 g/l or rose ≥160 g/l. The inhospital 30-day mortality was 25. 0% in patients with hemoglobin concentrations <100 g/l, 20. 4% in patients with hemoglobin concentrations of 100-119 g/l, 10. 6% in patients with hemoglobin concentrations of 120-139 g/l, 4. 3% in patients with hemoglobin concentrations of 140-159 g/l, and 8. 5% in patients with hemoglobin concentrations of 160 g/l or greater. The increase in risk of complications associated with a low hemoglobin concentration was more pronounced in patients with anemia than in patients without. Compared with patients with hemoglobin concentrations of 140-159 g/l, those with hemoglobin concentrations <140 g/l had more inhospital complications and those with hemoglobin concentrations ≥160 g/l also had more arrhythmia and pneumonia (P < 0. 001, respectively). As expected, a significant inverse correlation between hemoglobin concentrations and ages (r = -0. 51; P < 0. 001) was observed, and a significant positive correlation between hemoglobin concentrations and albumin concentrations and in the patients with acute myocardial infarction.
section_name: Figure 1 (abstract P233)

section_content: It is demonstrated in this study that a reverse J-shaped relationship between baseline hemoglobin values and major adverse cardiovascular events is observed in patients with acute myocardial infarction. There is a greater incidence of patients with a hemoglobin concentration on admission in the elderly population than that in the younger one.
section_name: Conclusion

section_content: Anaemia at the moment of admittance is associated with higher heart failure and mortality among patients with acute coronary syndrome
section_name: P235

section_content: The prevalence of anaemia (Hb < 11 g/dl in women and Hb < 12 g/dl in men) in patients with an ACS was 15. 4%. This group was characterised by the following: woman (P < 0. 0001), higher age (P = 0. 0001), less weight (P = 0. 01), higher frequency of high blood pressure (P = 0. 0001), diabetes mellitus (P = 0. 0001), history of ischaemic heart disease (P = 0. 002) and peripheral artery disease (P = 0. 0001). This group presented a major proportion of the NSTEMI (P = 0. 015), higher level of renal dysfunction (77% to 32%, P = 0. 0001), and microalbuminuria (61% to 32%, P = 0. 0001). Patients with anaemia presented a worse intrahospital prognosis: major incidence of cardiac insufficiency (42% to 20%, P = 0. 0001), refractory angina pectoris (14% to 6%, P = 0. 01), more electric complications (12% to 9%, P = 0. 01) and a higher mortality (14% to 7%, P = 0. 009). The presence of anaemia was an independent predictor of cardiac insufficiency and death at the moment of admittance to the CCU (OR = 2. 20, 95% CI = 1. 10- Introduction Anemia has been shown to be a powerful and independent predictor of 30-day outcomes among patients presenting with acute coronary syndrome. However, there are limited and conflicting data about its long-term independent predictive value in this setting. 

Objectives To investigate the long-term prognostic impact of anemia in patients with ST-elevation acute myocardial infarction (STEMI) treated by primary coronary angioplasty (PCA). Methods Retrospectively, from January 2001 to December 2003, we studied 298 consecutive patients with STEMI treated with PCA. Patients were classified into two groups according to having anemia or nonanemia at admission (for men Hb < 13 vs ≥13 g/dl, and for women Hb < 12 vs ≥12 g/dl). We defined the composite endpoint as death or rehospitalization for heart failure or acute coronary event. The average follow-up time was 24 months and was determined in 97%. 

Results Anemia was present in 41 patients (14%). At the end of follow-up, 109 patients (37%) developed ≥1 component of the composite endpoint (52 deaths and 66 rehospitalization). The event-free survival was 62% in the group with anemia versus 82% in the other group (P < 0. 001). After controlling for a variety of baseline clinical, laboratory, and angiographic variables, anemia was a strong and independent predictor of death or rehospitalization for heart failure or acute coronary event (HR 1. 96, 95% CI 1. 21-3. 17, P = 0. 006). Figure 1 shows that patients with anemia present a worse prognosis.
section_name: Results

section_content: The aim of this study was to investigate the relationship between blood pressure and plasma magnesium levels in patients referred to the emergency department with hypertensive attack. Epidemiological evidence on the effects of magnesium on blood pressure is inconsistent. Metabolic and experimental studies suggest that magnesium may have a role in the regulation of blood pressure. Magnesium regulates various ion channels in many tissues, including those of the cardiovascular system. Magnesium is the second most abundant intracellular cation, and the important element that has numerous biological functions in the cardiovascular system. Furthermore, magnesium acts as a calcium antagonist, regulating the calcium metabolism. Methods Patients were included who were taken to the emergency department due to hypertensive attack. Their age, gender, systolic and diastolic blood pressure were recorded. In order to see the plasma magnesium levels, venous blood samples were taken. The results were compared with a chi-square test. The values P < 0. 05 were accepted as significant. 

Results Seventy-three patients (35 of whom were female, 38 males) were included in the study. The average age was 47 ± 6. 3 (ranging from 33 to 68 years). The average blood pressure of the patients was found as systolic 200 ± 10 (range 185-240) mmHg, diastolic 105 ± 7 (range 95-110) mmHg. The average plasma magnesium levels were 1. 4 ± 0. 3 (range 0. 9-2. 2) mg/l. The plasma magnesium levels were low in 29 patients (ranging from 0. 9 to 1. 7 mg/l). There was a negative relationship systolic blood pressure and plasma magnesium level (P < 0. 05). In addition, there was a negative relationship diastolic blood pressure and plasma magnesium level (P < 0. 05). Conclusion Low plasma magnesium levels would be an important factor for elevated blood pressure and hypertensive attack. Methods Four hundred and twenty-eight patients with an ACS, admitted to our coronary care unit (CCU), were studied prospectively. Sixty-three per cent presented a non-ST-segment elevation myocardial infarction (NSTEMI) and 37% a ST-segment elevation myocardial infarction (STEMI). During their hospitalization we registered cardiovascular risk factors: we determined the presence of microalbuminuria (>3 mg/dl) in a 24-hour urine sample. We also took blood samples during the first 24 hours of their admittance to the CCU for a complete hemogram, levels of total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides, creatinine, creatinine clearance (Cockroft-Gault equation), glucose, HbAc1, high-sensibility C-reactive protein, Cystatin C and a follow-up of levels of Troponin, CK and CK-MB. All patients were submitted to a coronary angiography in the first 72 hours to give a clinical score to their coronary artery disease (disease of one, two or three arteries).
section_name: Introduction

section_content: We determined the Cystatin C level in 59 patients (16 females and 43 males). In 36% (21 patients) we found normal levels (<0. 95; 0. 80 ± 0. 9), called group 1. In the other group (group 2) we found higher levels of Cystatin C (>0. 95; 1. 63 ± 0. 77). Patients in group 2 presented a higher age, a higher frequency of high blood pressure, worse Killip class score at the moment of admittance, higher inflammatory activity (leucocytosis, P = 0. 001 and higher levels of C reactive protein, P = 0. 005), higher grade of renal dysfunction (P = 0. 001) and anaemia (P = 0. 06). Patients in group 2 presented a worse intrahospital prognosis with a higher incidence of cardiac insufficiency (45% to 14%, P = 0. 01), ventricular arrhythmias (29% to 5%, P = 0. 05), pericardial effusion (18% to 0%, P = 0. 05) and a higher mortality (21% to 5%, P = 0. 08). In the multivariant analysis, Cystatin C was an independent predictor of cardiac insufficiency (OR = 4. 5, 95% CI 1. 1-20. 8, P = 0. 05). Introduction Determination of the glomerular filtration rate (GFR) in patients with an acute coronary syndrome (ACS) has an important prognostic value. The presence of microalbuminuria (MA) is a known risk factor in patients with hypertension and diabetes. We know less about the effect of reduction of the GFR on patients with an ACS. Method Four hundred and twenty-eight patients with an ACS, admitted to our coronary care unit (CCU), were studied prospectively. Sixty-three percent presented a non-ST-segment elevation myocardial infarction and 37% a ST-segment elevation myocardial infarction. During their hospitalization we registered cardiovascular risk factors; we determined the presence of MA (>3 mg/dl) in a 24-hour urine sample. We also took blood samples during the first 24 hours of their admittance to the CCU for a complete hemogram, levels of total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides, creatinine, creatinine clearance (Cockroft-Gault equation), glucose, HbAc1, high-sensibility Creactive protein and a follow-up of levels of Troponin, CK and CK-MB.
section_name: Results

section_content: Results Thirty-nine percent of the patients with an ACS presented a GFR less than 60 ml/minute, and 36% presented MA at the moment of admittance to the CCU. Forty-four percent of the patients with a GFR less than 60 ml/minute also presented MA; on the contrary, only 32% of the patients with a GFR more than 60 ml/minute did so (P = 0. 01). This group contains significantly more women (P = 0. 001), more history of ischemic brain events and peripheral artery disease (P = 0. 03), worse Killip score at the moment of admittance (P = 0. 001), more development of cardiac insufficiency (P = 0. 003) and a higher mortality during hospital stay (P = 0. 03). 

The intrahospital survival of patients with GFR less than 60 ml/minute and MA was 79%, to 96% in patients without MA and a GFR more than 60 ml/minute (P = 0. 01; Log-rank test = 6). Patients with a GFR less than 60 ml/minute but without MA presented an intrahospital survival of 85%. In the multivariant analysis a GFR less than 60 ml/minute (OR = 2. 0; 95% CI However, there are scant data about the predictive value of these biomarkers in combination. Methods A total of 577 consecutive patients (mean age: 73 ± 9 years), who were hospitalized for acute decompensation of NYHA class III/IV (65. 3% of ischemic etiology) low-output (mean LVEF: 22 ± 5) CHF, were studied. Biochemical markers were measured upon admission. The incidence of 31-day death was the prespecified primary endpoint.
section_name: Critical

section_content: The incidence of the primary endpoint was 17. 7%. By multivariate Cox analysis, including baseline characteristics and the study biomarkers, elevated circulating levels of TNFα (RR = 2. 1; P < 0. 001), BNP (RR = 3. 5; P < 0. 001) and cTnI (RR = 3. 8; P < 0. 001) were independently associated with the primary endpoint. When the patients were divided according to the number of positive biomarkers (estimated by ROC analysis) there was a significant gradual increase in the rate of the primary endpoint with increasing of the number of the positive biomarkers (4. 1%, 10%, 21. 5% and 53. 5% 31-day mortality rate for patients with zero, one, two and three positive biomarkers, respectively; P < 0. 001) (Figure 1 ).
section_name: Results

section_content: The present results suggest that in patients hospitalized due to acutely decompensated severe low-output CHF, serum levels of TNFα, BNP and cTnI can be used in combination for enhanced early risk stratification. 

Available online http://ccforum. com/supplements/11/S2
section_name: Conclusions

section_content: Introduction Over the past decade, coronary revascularisation has helped reduce mortality and morbidity rates from coronary artery disease. In addition to revascularisation, long-term prognosis is dependent on successful implementation of secondary prevention, in particular the use of aspirin, statins, angiotensin-converting enzyme (ACE) inhibitors and, in many, β-blockers. Previous studies have highlighted the under-utilisation of secondary preventative strategies in this patient population. A focused review of secondary preventative medication at the time of revascularisation provides an excellent opportunity to ensure optimal use of these agents. Our aim was to identify the proportion of patients undergoing nonemergency surgical revascularisation discharged on these four secondary preventative medications. 

Methods A retrospective analysis of our inhouse cardiothoracic surgical database was performed. All patients had undergone surgical revascularisation between January 2003 and November 2006. Only patients undergoing coronary artery bypass grafting were included. 

Results A total of 2,749 consecutive patients were included in the analysis, mean age 65. 5 years (±9. 2). In total, 2,302 isolated coronary artery bypass grafting procedures and 447 combined procedures were performed. See Table 1.
section_name: Figure 1 (abstract P248)

section_content: Although the utilisation of these preventive therapies has improved compared with previous studies, additional improvements could be made and in particular there is a continuing under-utilisation of ACE inhibitors. There are several reasons why ACE inhibitors might not be used in the early postoperative phase (hypotension, temporary renal dysfunction, etc. ). These results reinforce the need to review these patients following recovery from surgery with a view to optimising secondary preventive treatment. This may best be done in community secondary prevention clinics with agreed guidelines. Vasoplegic shock was defined as vasoplegic patients that needed norepinephrine for at least 4 hours, after failure to respond to appropriate volume expansion. Excessive bleeding was defined as blood loss >1 l/24 hours, while total bleeding was considered as blood loss until chest tube withdrawal. Demographic variables, surgical procedures and postoperative variables were collected. 

We recorded data related to coagulation, fibrinolysis, complement, inflammation, blood loss at different time points, preoperative, at 0, 4 and 24 hours after surgery, and hemoderivative requirements. We used the Pearson chi-squared test, the Fisher exact test, the Student t test and the Mann-Whitney U test for nonparametric variables. SPSS version 12. 1 was used. 

Results Seventeen (34%) patients had VS, 11 (65%) men and six (35%) women. Longer aortic clamping time (P = 0. 007) and CPB time (P = 0. 013) were associated with VS. These patients showed a higher cardiac index at 4 hours (P < 0. 001) and lactic acid within the first 24 hours. Seven of these patients (41%) fulfilled vasoplegic shock criteria (P < 0. 001). We found higher levels of IL-6 at 0 hours (P = 0. 02) and 4 hours (P = 0. 001), and soluble TNF receptor at 0 hours (P = 0. 044). At ICU admission (0 hours) there was a higher coagulation activation: INR (P = 0. 005), fibrinogen (P = 0. 001), antithrombin (P = 0. 007); lower levels of plasminogen activator inhibitor-1 (P = 0. 023) as well as lower plasminogen activator inhibitor-1/tissue-plasminogen activator ratio (P = 0. 021), and higher levels of D-dimer (P = 0. 041); lower levels of C3 (P = 0. 023), B factor (P = 0. 013), C4 (P = 0. 015) as well as a significantly higher decrease between preoperative and 0-hour levels of C1-inhibitor, C4, C3 and B factor. Lower levels of leptins at 0, 4 and 24 hours were found. Vasoplegic patients showed higher blood losses along all time points (Figure 1 ), higher incidence of excessive bleeding (60% vs 40%; P = 0. 011) and required more hemoderivatives during the ICU stay, plasma (P = 0. 016) and platelets (P = 0. 002). 

Conclusions VS post-CPB was associated with activation of serin protease systems, which leads to higher blood loss and excessive bleeding.
section_name: Conclusion

section_name: P255

section_content: (28%) patients. According to the PAI-1 polymorphism, vasoplegia criteria were found in one (5. 5%) 4G/G carrier, in seven (39%) 4G/5G carriers and in 10 (55. 5%) 5G/G carriers (P = 0. 012) (Figure 1 ). The post-hoc power for PAI-1 polymorphism and vasoplegia was 0. 85. After controlling for temperature, clamping time, antifibrinolytics, body mass index and ACE inhibitors, the 5G/G genotype was independently associated with vasoplegia (P = 0. 017); OR: 24. 6 (95% CI: Introduction Body mass index (BMI) has been described as a risk factor for coronary artery disease, but association with postoperative bleeding after cardiopulmonary bypass (CPB) has been found in several studies recently. Nevertheless the strong relationship between a low BMI and excessive bleeding remains unexplained. We sought to investigate the BMI role on postoperative bleeding and its relationship with leptin levels, coagulation, fibrinolysis and complement parameters. Methods We performed a nested case-control study of 26 patients, who did not receive antifibrinolytic prophylaxis. We used Bray's classification for BMI: lower than 27 kg/m 2 ; 27-30 kg/m 2 ; higher than 30 kg/m 2. Variables were collected preoperatively, at ICU admission (0 hours), and at 4 and 24 hours after surgery. 

Excessive bleeding was defined as blood loss higher than 1 l in the first 24 hours after intervention. The associations of BMI with demographic factors, leptin levels, coagulation, fibrinolysis and complement parameters were analyzed. Pearson's chi-squared test and Fisher's exact test were used, the Student t test for independent groups and the Mann-Whitney U test for nonparametric variables. 

Results In total, 61. 5% of patients showed BMI >27 kg/m 2 (median 28 kg/m 2, range 25. 2-30. 7 kg/m 2 ). Patients with BMI lower than 26. 4 kg/m 2 (25-28 kg/m 2 ) presented excessive bleeding (P = 0. 026). Leptin levels after adjusting by BMI were significantly associated with excessive bleeding at all postoperative time points (P < 0. 001, P < 0. 001 and P = 0. 004, respectively) (Figure 1 ). BMI presented a direct correlation with leptins, fibrinogen and plasminogen activator inhibitor-1 (PAI-1) on arrival, meanwhile 24-hour bleeding showed an inverse correlation with the same parameters and BMI (Table 1 ). Patients with BMI < 27 kg/m 2 had significantly greater coagulation, fibrinolysis and complement activation. Therefore these patients required significantly greater hemoderivatives. Monitoring of the mitochondrial NADH redox state (an indicator of intracellular oxygen levels) together with microcirculatory blood flow (TBF) and with oxygenation (HbO 2 ) could serve as a preferred approach to evaluate tissue O 2 balance or viability. We hypothesize that in the presence of reduced oxygen delivery and extraction, blood flow will be redistributed in order to protect the most vital organs by increasing their regional blood flow, while O 2 delivery to the less vital organs will diminish. Thus, the NADH redox state of less vital organs could serve as an indicator of overall O 2 imbalance as well as an endpoint of resuscitation. We have therefore developed an optical device embedded in a Foley catheter to provide real-time data on the NADH redox state, TBF and HbO 2 in critically ill patients. The CritiView is a computerized optical device that integrates hardware and software in order to provide real-time information of tissue viability [1]. A modified three-way Foley catheter that contains a fiberoptic probe connects the CritiView to the mucosal side of the urethral wall. We have used this device in five female pigs that underwent graded hemorrhage, and in four patients who were monitored during aortic abdominal aneurysm operations. These preliminary swine model and human studies confirm the feasibility of collecting information about mitochondrial function from the urethral wall. The main effects of graded hemorrhage started when the blood volume decreased by 30%. At 40% blood loss, minimal levels of TBF and HbO 2 were correlated to the maximal NADH levels. The values of the three parameters returned to baseline after retransfusion of the shed blood. Aortic clamping in patients led to a significant decrease in TBF and HbO
section_name: S105

section_content: The outcome of liver transplantation is steadily improving. There is still need for earlier detection of complications such as hepatic artery thrombosis and rejection. In an earlier in vitro study we showed that the CMA microdialysis system with a 100 kDa pore size membrane can be used to measure the selected cytokines and complement. We monitored patients undergoing liver transplantation with microdialysis continuously for a week postoperatively, and analyzed both parameters to detect ischemia, and cytokines and anaphylatoxins to explore whether rejection was detected earlier than with the standard methods. Methods Twenty patients undergoing 22 liver transplantations were included. Two microdialysis catheter were introduced in the liver and one in subcutaneous tissue. We analyzed metabolic parameters (glucose, pyruvate, glycerol and lactate), and IL-6, IL-8, MCP-1, IP-10, and C5a. Results Fourteen patients had an uneventful course postoperatively, judged clinically and by routine biochemical markers and ultrasound Doppler. These patients had a median lactate starting at 3. 5 mM (2 hours after reperfusion) falling to below 2 mM during the first 24 hours, and thereafter staying low. The L/P ratio (a specific measure of ischemia) dropped from about 20 to below 10. These patients had a steady rise in IP-10 from 200 to 3,000 pg/ml, and also a slight raise in IL-6 initially. Case 1. The male patient had a steadily increasing L/P ratio during the 7 days of microdialysis measurements, indicating an insufficient blood supply. He underwent surgery 5 days later and a hepatic artery thrombosis was found. A biopsy was done during the operation showing an acute rejection. There was a significant rise in IP-10 to 13,000 pg/ml 7 days before the diagnosis of rejection. Case 2. 

The female patient had an acute rejection verified by biopsies on day 10 postoperatively. Her IL-8, IP-10 and C5a increased 10-fold to 100-fold in the liver 3 days earlier than an increase in liver enzymes and 5 days before the rejection was verified by biopsy.
section_name: Introduction

section_content: We have described the normal course of the four cytokines IL-6, IL-8, MCP-1 and IP-10 and complement C5a after liver transplantation, as well as metabolic parameters to detect ischemia. In two patients with rejection we found a large increase in IP-10, IL-8 and complement split-product C5a in the liver but not in the subcutis 3-5 days before any other parameter of liver injury.
section_name: Conclusion

section_content: Microcirculatory hemodynamic alterations during cardiac luxation in off-pump coronary artery bypass grafting surgery Introduction Cardiac surgery patients are at low risk for postoperative complications, but these may involve multiple organ failure with a high mortality rate. These complications may be related to occurrence of organ ischemia and reperfusion during and just after surgery. We investigated whether microcirculatory flow alterations occur during cardiac surgery. Methods We observed 10 consecutive patients who underwent cardiac surgery with cardiopulmonary bypass (CPB). The microcirculation was studied using sidestream dark field (SDF) imaging. The sublingual capillary flow was estimated using a semiquantitative microvascular flow index (MFI) in small (diameter 10-25 µm), medium (25-50 µm), and large (50-100 µm) sized microvessels (0 = none, 1 = intermittent, 2 = sluggish, 3 = continuous flow). SDF imaging was performed at least three times per time period (that is, at baseline, after starting CPB and after surgery) in each patient. Data are presented as the median and interquartile range.
section_name: P262

section_content: The MFI decreased in all sizes of microvessels <15 minutes after starting CPB in comparison with baseline (P < 0. 05, Table 1 ). After starting CPB, the mean arterial pressure (MAP) was lower (61 mmHg (53-65 mmHg)) than at baseline (100 mmHg (92-118 mmHg); P = 0. 01). After return to the ICU, the MFI increased (P < 0. 05) and returned to baseline values in all microvessels. 

Conclusions SDF imaging can be used as a bedside tool to evaluate sublingual microcirculatory changes during cardiac surgery. Despite maintaining common circulatory parameters during CPB, the nonpulsatile status, hypothermia, and the temporary drop in MAP after starting CPB were associated with decreased sublingual MFI, which normalized after surgery. Further studies should reveal whether these changes are related to outcome. Results Nonsurvivors demonstrated a significantly higher MODS score when compared with survivors (P = 0. 004). Norepinephrine requirements were higher in nonsurvivors (P = 0. 018). Nonsurvivors had higher arterial lactate levels (P = 0. 046), decreased arterial pH levels (P = 0. 001), and decreased arterial PO 2 values (P = 0. 013) when compared with survivors. A higher oscillation frequency of skin microvasculature at rest (P = 0. 033) and after an ischemic stimulus (P = 0. 009) was observed in nonsurvivors. No differences were observed in reactive hyperemia response between groups. The flowmotion frequency observed in reactive hyperemia was associated with the severity of the MODS (P = 0. 009), and -although not statistically significant -arterial lactate concentration (P = 0. 052). Conclusion An increased skin microvascular oscillation frequency during rest and after an ischemic stimulus is associated with increased mortality in patients suffering from MODS. We suggest that the underlying mechanism of the increased flowmotion could be a response of the skin microvasculature to hypoxia or to an impaired oxygen utilization of the skin tissue.
section_name: Results

section_name: P265

section_content: V Cerny, Z Turek, R Parizkova, P Dostal University Hospital Hradec Kralove, Czech Republic Critical Care 2007, 11(Suppl 2):P267 (doi: 10. 1186/cc5427) Introduction Intermittent positive pressure ventilation (IPPV) may be accompanied by alteration of microcirculation [1, 2] ; however, the effect of IPPV is not mentioned in the interpretation of the results of studies evaluating microcirculation using orthogonal polarization spectral or sidestream dark-field imaging. This study aimed to evaluate the effect of IPPV on microcirculation in the skeleton muscles and in the serosa of the small intestine in rats. Methods Ten animals were tracheostomized and prepared for microcirculation study; after tissue preparation, five rats were allowed to breath spontaneously (Group SB = spontaneous breathing), and five rats (Group IPPV) were connected to a small animal ventilator (IPPV: FiO 2 0. 21, respiratory rate 60/min, tidal volume 10 ml/kg, inspiratory time 50% of respiratory cycle, and 2 cmH 2 O PEEP). Sidestream dark-field images were obtained from the quadriceps femoris muscle (QFM) and serosa surface of the ileum. The arterial blood pressure and rectal temperature were also recorded. The functional capillary density (FCD) and small and medium vessels rate were analysed offline using AVA V1. 0 software (AMC, University of Amsterdam, The Netherlands), P ≤ 0. 05.
section_name: P267 Effect of intermittent positive pressure ventilation on the skeletal muscle and small intestine microcirculation in rats

section_content: The FCD was decreased significantly in QFM in rats with IPPV with respect to Group SB (184 ± 27 resp. 197 ± 61 cm/cm 2 ), but the FCD of the intestinal serosa was not affected by IPPV (265 ± 46 resp. 267 ± 25 cm/cm 2 ). There were no differences in mean blood pressure and temperature between groups (128 ± 7 Torr and 36. 6 ± 0. 1°C in Group SB, or 128 ± 10 Torr and 36. 5 ± 0. 1°C in Group IPPV).
section_name: Results

section_content: The use of IPPV should be taken into account in the interpretation of the studies examining the changes in microcirculation in rats.
section_name: Conclusion

section_content: We examined sublingual microvascular changes in experimental human endotoxemia. Changes in microcirculation and mitochondrial dysfunction appear to be key mechanisms in sepsis, since they can lead to regional mismatch of oxygen supply and demand. Lipopolysaccharide (LPS) can be used to induce endotoxemia as a model of sepsis, but the effects on microcirculatory perfusion have not been tested before, particularly after tolerance induction during repeated challenges of LPS. Methods Six healthy volunteers received an intravenous injection of 2 ng/kg Escherichia coli LPS to induce endotoxemia on five consecutive days. Microvascular perfusion was sublingually measured using sidestream darkfield imaging just before, and 2 and 4 hours after LPS injection on day 1. All measurements were repeated on day 5 of LPS administration. Sublingual capillary flow was estimated using a semiquantative microvascular flow index (MFI) in small (10-25 µm), medium (25-50 µm) and large-sized (50-100 µm) microvessels (no flow, 0; intermittent flow, 1; sluggish flow, 2; and continuous flow, 3 Introduction Shock is defined currently as tissue oxygen metabolic disorders. It is most important to understand oxygen metabolic disorders in individual tissue. Microdialysis allows the determination of the metabolic condition in regional tissue and it appears ideal to determine the regional metabolic tissue conditions during endotoxemia. Objective This study was designed to assess the regional metabolic tissue conditions on markers of tissue metabolism (lactate in regional tissue: tissue lactate (TL)) and tissue partial oxygen pressure (PtO 2 ) during severe endotoxemia and to compare them with variables determined by standard monitoring (hemodynamics, blood gas analysis, blood lactate (BL)).
section_name: Introduction

section_content: Male Wister rats (body weight 270-300 g) were used for this study. The rats in the control group (n = 6) were injected with saline of 2 ml intraperitoneally, and the rats in the experimental group (n = 6) were treated with intraperitoneal injection of lipopolysaccharide (LPS) of 40 mg/kg. The hemodynamic parameters, arterial blood gas analysis, BL and PtO 2 were measured in both groups. TL and pyruvate in subcutaneous tissue were measured using microdialysis. These parameters were measured every 50 minutes until 400 minutes after LPS was administered.
section_name: Materials and methods

section_content: In the control group, all parameters were not changed during the observation period of 400 minutes. In the experimental group, the mean arterial pressure (MAP) remained fairly stable until 300 minutes after injection of LPS, and the MAP gradually decreased subsequently. While the MAP was maintained, the PtO 2 gradually decreased linearly (Figure 1 ). TL increased with time linearly. Meanwhile, BL did not change from 150 to 250 minutes; after 300 minutes it increased abruptly in the experimental group (Figure 2 ). Conclusions In our experimental endotoxemia model it has been shown that partial pressure of oxygen in subcutaneous tissue decreased even if systemic blood pressure was maintained. Boekstegers and colleagues [1] Shunting of the microcirculation contributes to the pathology of sepsis and septic shock. In this study, we hypothesize that shunting of the microcirculation occurs after superior mesenteric artery (SMA) ischemia (occlusion) and reperfusion, and we explore functional consequences using intravital microscopy. Spontaneously breathing animals (rats) (n = 30) underwent occlusion of the SMA for 0 (controls), 30 or 60 minutes followed by reperfusion (4 hours) with normal saline. Leukocyte-endothelial interactions in mesenteric venules were quantified in an exteriorized ileal loop using intravital microscopy. Abdominal blood flow was recorded continuously, and arterial blood gases were analyzed at intervals. Continuous SMA blood flow measurements were performed in comparable groups without exteriorizing an ileal loop. Adherent leukocytes increased shortly after reperfusion in ischemia groups, and plateaued in these groups. The centerline velocity and shear rate in the recorded venules were significantly reduced after reperfusion down to low-flow/no-flow in animals undergoing 60 minutes of mesenteric artery occlusion compared with animals with 30 minutes occlusion and controls, whereas perfusion of the SMA and ileal vessels persisted. The microcirculatory changes in animals with 60 minutes occlusion were accompanied by progressive metabolic acidosis, substantially larger volumes of intravenous fluids needed to support arterial blood pressure and significantly reduced survival (30%). In the groups with continuous SMA blood flow measurements, SMA blood flow increased in Methods All adult patients admitted to the ICU after surgery who underwent protocolised haemodynamic optimisation were included. All patients had STO 2 recorded over the thenar eminence using an Inspectra™ 325 for the first 8 hours of their stay.
section_name: Results

section_content: We found a significant correlation between the changes in STO 2 and oxygen delivery index (DO 2 I) over the first 8 hours of intensive care stay (n = 40, correlation coefficient of 0. 947, P = 0. 0001, Figure 1 ). We classified patients who achieved DO 2 I > 600 ml/min/m 2 as responders. These responders had higher STO 2 values by 3 hours of optimisation, a change that remained significant throughout the duration of the study (Figure 2 ). Introduction Drugs used to induce and maintain general anesthesia have deep effects on the cardiovascular system. To our knowledge there are no studies investigating microvascular compliance during general anesthesia with a noninvasive approach based on near-infrared spectroscopy (NIRS) technology. Methods We randomized 36 healthy subjects undergoing maxillofacial surgery to receive general anesthesia with a sevofluoraneremifentanil (Group S) or a propofol-remifentanil association (Group P). We collected noninvasive measures of hemoglobin concentration from the gastrocnemius muscle of the subjects using a NIRS device (NIMO, NIROX srl, Italy), which performs quantitative assessments of the [HbO 2 ] and [Hb] exploiting precise absorption measurements close to the absorption peak of the water. Data were collected during a series of venous occlusions at different cuff pressures, before and after 30 minutes from induction of general anesthesia. The muscle blood volume and microvascular compliance were obtained with a process previously described elsewhere [1]. Data were analyzed with a one-way analysis of variance test.
section_name: Results

section_content: Results Demographic data of the 36 subjects were similar in both Groups S and P. General anesthesia reduced the heart rate and mean arterial pressure and increased the total muscle blood volume in both groups (Group S: from 2. 4 ± 0. 9 to 3. 2 ± 1. 2 ml/ 100 ml; Group P: from 2. 4 ± 1. 2 to 3. 5 ± 1. 8 ml/100 ml; P < 0. 05). During general anesthesia, despite no differences in muscle blood volume between the two groups, sevofluoraneremifentanil significantly decreased microvascular compliance (from 0. 15 ± 0. 08 to 0. 09 ± 0. 04 ml/mmHg/100 ml; P = 0. 001) whereas propofol-remifentanil did not (from 0. 15 ± 0. 08 to 0. 16 ± 0. 11 ml/mmHg/100 ml; P = 0. 39). 

Available online http://ccforum. com/supplements/11/S2 1 ). There was weak but significant correlation between StO 2 and age (P < 0. 0001, r = -0. 28), StO 2 and lactate (P = 0. 035, r = -0. 12) and StO 2 and systolic blood pressure (P < 0. 0001, r = 0. 26). 1 ). Ranges of errors were: CO (-77/+100%), SVR (-94/+303%), GEDVi (-88/+135%), SVV (-91/+367%), EVLWi (-76/+650%). There was a significant underestimation of CO (P < 0. 00001) and GEDVi (P < 0. 0003), and overestimation of SVR (P < 0. 003) and SVV (P < 0. 0002). 

The 240 self-ratings (scale of 1-5, [
section_name: Conclusion Changes in STO

section_content: We found a statistically significant correlation of both inspiratory and expiratory IVC diameter with central venous pressure (P = 0. 004 and P = 0. 001), extravascular lung water index (P = 0. 001 and P < 0. 001), intrathoracic blood volume index (P = 0. 026 and P = 0. 05), the intrathoracic thermal volume (both P < 0. 001), and the paO 2 /FiO 2 oxygenation index (P = 0. 007 and P = 0. 008, respectively). Conclusions Sonographic determination of the IVC diameter is useful in the assessment of volume status in mechanically ventilated septic patients. This approach is rapidly available, noninvasive, inexpensive, easy to learn and applicable in almost any clinical situation without doing harm. IVC sonography may contribute to a faster, more goal-oriented optimization of fluid status and may help to identify patients in whom deleterious volume expansion should be avoided. It remains to be elucidated whether this approach influences the outcome of septic patients.
section_name: Results

section_content: R Bilkovski 1, J Martini 1, R Phillips 1 ). We evaluated the accuracy, precision, responsiveness, and reliability of NICOM for detecting CO changes. Tolerance for each of these parameters was specified prospectively. 

Results A total of 65,888 pairs of CO measurements were collected. Mean reference values for PAC-CCO ranged from 2. 79 to 9. 27 l/min. During periods of stable PAC-CCO (slope < ±10%, 2SD/mean <20%), the correlation between NICOM and PAC-CCO was R = 0. 82; bias was +0. 16 ± 0. 52 l/min (+4. 0 ± 11. 3%), and the relative error was 9. 1 ± 7. 8%. In 85% of patients the relative error was <20%. During periods of increasing CO, slopes were similar with the two methods in 96% of patients and intraclass correlation was positive in 96%. Corresponding values during periods of decreasing CO were 90% and 84%, respectively. Precision was always better with NICOM than with PAC-CCO. During hemodynamic challenges, changes were 3. 1 ± 3. 8 minutes faster with NICOM (P < 0. 01) and amplitude of changes were not different (not significant). Finally, sensitivity of the NICOM for detecting significant directional changes was 93% and specificity was 93%. 

Conclusion CO measured by NICOM had most often acceptable accuracy, precision, and responsiveness in a wide range of circulatory situations.
section_name: P288 Noninvasive cardiac output: accuracy between the ultrasound cardiac output monitor and the esophageal Doppler monitor

section_content: M Cecconi 1, J Poloniecki 2, G Della Rocca 3, J Ball 1, R Grounds Objective To compare the reliability of vascular pedicle width (VPW) as an indicator of overload, in patients of a general ICU, with a method of invasive haemodynamic monitoring that has proved its efficacy in the literature and in everyday practice.
section_name: P290 Method comparison -a new approach to implementing the Bland-Altman analysis to estimate the precision of a new method: tested on 30 critically ill patients monitored with pulse pressure analysis and continuous cardiac output vs intermittent thermodilution

section_content: The VPW, which represents the mediastinal silhouette of the great vessels, was compared with the haemodynamic measurements, which were obtained with the method of transpulmonary thermodilution (PiCCO Plus; Pulsion, Munich, Germany). We measured the VPW in anteroposterior chest X-rays in the supine position, with standard parameters, in 100 patients without prior cardiac surgery, prior mediastinal irradiation, obesity, severe acute respiratory distress syndrome and positive end-expiratory pressure > 7. 5 cmH 2 O. In every patient we performed invasive haemodynamic monitoring with the PiCCO Plus. An intrathoracic blood volume index (ITBI) > 1,000 ml/m 2, global end-diastolic index (GEDI) > 800 ml/m 2, and extravascular lung water index (ELWI) > 7. 0 ml/kg were considered the markers of significant volume overload. After further refinement, 27 patients fulfilled the above criteria and were considered eligible to be included in the study.
section_name: Patients and methods

section_content: The mean VPW in overloaded patients was 75. 14 mm compared with a mean of 64. 71 mm for the rest. The results were subsequently analyzed using Spearman's nonparametric test and we found correlation (0. 785, 0. 710, and 0. 510) between VPW and the GEDI, ITBI, and ELWI, respectively. The results were considered statistically significant (P < 0. 000, P < 0. 000, and P < 0. 005, respectively).
section_name: Results

section_content: The VPW, when appropriately assessed at the bedside by the same physician and therefore avoiding the possible bias, using portable chest X-rays, might give very useful information regarding the volume status of the patients, results that are comparable in their efficacy with those obtained with invasive and more expensive methods.
section_name: Conclusion

section_content: Introduction Reliable continuous hemodynamic monitoring of critically ill patients is essential for effective volume management and adequate administration of vasoactive drugs. The PiCCO system allows continuous measurement of the cardiac index using arterial pulse contour analysis. Calibration of this system by transpulmonary thermodilution is recommended every 8 hours. In this study we compared the difference of the continuous measurement of the cardiac index using the arterial pulse contour analysis (CIpc) with the cardiac index acquired by the transpulmonary thermodilution (CItd) when calibrating the system. Methods Our study includes 140 measurements in 10 critically ill patients (eight males, two females, age 37-84 years, mean 64. 1 ± 13. 0 years) requiring hemodynamic monitoring with the PiCCO system. Five patients had septic shock, three hepatorenal syndrome and two acute heart failure. First the CIpc was recorded immediately before the next calibration and afterwards the CItd was measured three times, which resulted in a simultaneous calibration of the pulse contour algorithm of the PiCCO system. We performed a mean of 14 ± 9. 4 measurements per patient. The time-lag between the measurements was 12 hours 54 minutes ± 7 hours 47 minutes.
section_name: P292 Reliability of the continuous cardiac index measurement using the pulse contour analysis of the PiCCO system

section_content: The comparison of the CIpc immediately before calibration and the calibration-derived CItd resulted in a correlation coefficient of 0. 84 with a P value of 0. 02. In the Bland-Altman analysis the CIpc was a mean 0. 14 l/min/m 2 lower than the CItd. The standard deviation was 0. 72 l/min/m 2. There was no correlation of the timelag between the calibrations and the difference of CIpc and CItd (r = -0. 03; P = 0. 13).
section_name: Results

section_content: The PiCCO system allows a reliable continuous measurement of the cardiac index using the pulse contour analysis. 

In our study we could not find an increased difference of CIpc and CItd even with longer time periods between the calibrations using transpulmonary thermodilution. Because calibration is easy to achieve and additional data for the intrathoracic blood volume and the extravascular lung water are obtained, a 12-hour period between the calibrations is reasonable.
section_name: Conclusion

section_content: Intensive Care Unit, Tunis, Tunisia Critical Care 2007, 11(Suppl 2):P293 (doi: 10. 1186/cc5453) Introduction PiCCO monitoring using the thermodilution technique has become an alternative method of invasive haemodynamic monitoring for the critically ill patient. Usually the results of an arbitrarily chosen number (one to five) of thermal indicator injections are averaged to increase the reliability of the measurement. The number of injections needed to achieve a given level of precision has, however, not previously been systematically investigated. We tried in this study to validate the accuracy of two injections instead of three injections.
section_name: P293 PiCCO monitoring -are two injections enough? S Alaya, S Abdellatif, R Nasri, H Ksouri, S Ben Lakhal

section_content: We analysed retrospectively all data (triplate measurements) obtained during the past 2 years by PiCCO monitoring: injection of 10 ml saline solution three times by the same operator. 

We compared the cardiac index (CI) obtained at each bolus, the average of the CI obtained at the first two injections (M1) and then the triplate (M2). 

Results Two hundred and forty-nine triplates were collected in 25 patients with septic shock, under mechanical ventilation. There were no significant differences in CI at each bolus. The average of the first two iced injections M1 = 3. 28 ± 1. 07 l/min/m 2. The average of the triplate M2 = 5. 74 ± 1. 07. Discussion Normally, we consider that 10-15% of variation in the CI signifies a change in the haemodynamic state. The difference between M1 and M2 exceeds 15%. In the literature, Nilsson and colleagues [1] demonstrated concerning the pulmonary arterial catheter that we need an average of at least four injections to be 95% confident. Results Sixty-five series were suitable for analysis. The CV showed a normal distribution and no correlation with the magnitude of the mean cardiac output. The mean CV for single lithium dilution was 12. 3%. The CV for the average of n lithium dilutions was 8. 6% for n = 2, 7. 1% for n = 3, 6. 1% for n = 4. 

Conclusions The CV for one lithium dilution was higher than clinically acceptable (12. 3 > 10%). The average of two lithium dilution measurements improves the precision by 30% and shows an excellent CV (that is, 8. 6%). When measuring cardiac output with LiDCO an average of two lithium dilution curves provide an excellent precision, and we suggest that in this population (medical/surgical) this approach should always be used when calibrating the pulse pressure algorithm (PulseCO) at the baseline.
section_name: Methods

section_content: Transpulmonary
section_name: P295

section_content: The median value of the CO ratio was 0. 95 (IQR 0. 88-1. 02), with a high variability across the patients, ranging from 0. 3 to 1. 41, whereas intrapatient variability was low, with a median CV of 3. 26% (IQR 1. 1-5. 3%). Although the ratio in COs between the two sites varied greatly, the difference between the median (range) arterial pressures was 2 mmHg (-3 to 8 mmHg). However, the pulse pressure difference between the two sites was generally large with a median (range) of 2 mmHg (-26 to 44 mmHg). Conclusions CO derived from blood pressure records at radial and femoral sites can appear similar when a patient population as a whole is considered. However, in individual patients, the difference between the two sites is large enough to be clinically unacceptable without a site-specific recalibration. 1 ). The mean difference of LiDCO from PiCCO overall was -5. 49 ± 21. 3%. The correlation coefficient r = 0. 73 (P = 0. 0166).
section_name: Results

section_name: P297 Measurement of intrathoracic blood volume by lithium dilution: comparison with thermodilution

section_content: PiCCO. There were significant differences (>30%) in only three out of 10 measurements. Combining the results of >1 lithium calibration may improve accuracy. These results are promising but a larger trial will be required. Method The senior physicians on ICUs in the South of England were surveyed via telephone. Information was collected as to which cardiac output monitors were available for use, which was their first choice and how often they measured cardiac output in severe sepsis.
section_name: Conclusion There was general agreement between LiDCO and

section_content: Results Forty-nine out of 52 ICUs units contacted completed the survey. Monitor availability can be seen in Figure 1 and use in severe sepsis compared with 2003 can be seen in Table 1. Yet, it is still not widely practised due to logistical difficulties associated with its use. We aimed to evaluate whether pulse power analysis calibrated by the lithium dilution technique, a pragmatic minimally invasive technique, can be used to optimize the oxygen delivery index (DO 2 I) in high-risk patients during major surgery. Methods Lithium indicator dilution and pulse power analysis were used to measure cardiac output and to calculate DO 2 I (LiDCOplus system). We prospectively evaluated the oxygen delivery pattern and perfusion variables of 26 high-risk patients (LiDCO group) submitted to major surgeries and goal-directed therapy during surgery and 8 hours postoperatively, aiming to maximize the DO 2 I to levels higher than 600 ml/min/m 2 using dobutamine and either 'restrictive' (4 ml/kg/min) or 'liberal' (12 ml/kg/min) strategies of intraoperative fluid management (partial results). Postoperatively both groups received 1. 5 ml/kg/min lactated ringer. Fluid challenge with 250 ml colloid was done in the presence of signs of hypovolemia and additional fluids were given if necessary. Patients were considered responders if they achieved the therapeutic goal. 

A historical group of 42 high-risk surgical patients in whom the therapeutic goals were to keep a mean arterial pressure between 80 and 110 mmHg, a central venous pressure between 6 and 12 cmH 2 O, hematocrit > 30% and urine output > 0. 5 ml/kg/hour in the first 24 hours after ICU admission was used as control.
section_name: P298 Impedance cardiography to assess hemodynamic status: a comparison with transpulmonary thermodilution

section_content: Results Median doses of 10 µg/kg/min and 7. 5 µg/kg/min dobutamine were used intraoperatively and postoperatively, respectively. A total of 75% and 84% of the patients were responders during surgery and postoperatively. However, a much better pattern of DO 2 I during surgery was seen in the liberal group than in the restrictive group (Figure 1 ).
section_name: S125

section_content: The use of a therapeutic approach guided by DO 2 I calculated by the LiDCO plus system, intraoperatively and postoperatively, seems to be a feasible and practical approach to guide oxygen delivery optimization therapy during major surgery in high-risk patients. Better perfusion and a much lower rate of complications were seen in optimized patients.
section_name: Conclusion

section_content: F Franchi 1, S Scolletta The DO 2 was calculated using the cardiac index measured by a pulse contour system (Hemoscan). The VCO 2 was measured under steady-state conditions using a CO 2 analyzer (930 Siemens Elema). The presence of AM (for example, hyperlactatemia, Lac+) was defined by an increase in Lac >2 mmol/l. Correlation analysis and the ROC test were applied. Results For a threshold value of DO 2 > 9 ml/kg, Lac showed an inverse relationship with SvO 2 (R = -0. 84; P < 0. 01) and DO 2 /VCO 2 ratio (R = -0. 73; P < 0. 01). Conversely, a direct correlation between Lac and RQ (R = 0. 66; P < 0. 01) was found. For a DO 2 < 9 ml/kg, SvO 2 did not correlate with Lac. Opposite, a direct correlation between Lac and RQ (R = 0. 81; P < 0. 01) was found. The DO 2 /VCO 2 ratio showed an inverse relationship with Lac (R = -0. 75; P < 0. 01). ROC curves to predict Lac+ were constructed. The areas under the ROC curves were 0. 40, 0. 74, and 0. 81 for SvO2, RQ, and DO2/VCO2 ratio, respectively. An optimal cutoff value of 3. 1 (sensitivity = 0. 70, specificity = 0. 77) was determined for the DO 2 /VCO 2 ratio predicting the presence of Lac+. Conclusions Our findings showed that, for a DO 2 > 9 ml/kg, the SVO 2, RQ, and DO 2 /VCO 2 ratio may be used interchangeably. For a DO 2 < 9 ml/kg, the DO 2 /VCO 2 ratio seems a more reliable predictor of AM than SvO 2 and RQ. The DO 2 /VCO 2 ratio can be simply and quickly calculated at the bedside because pulse wave analysis allows the DO 2 to be frequently calculated, and because the CO 2 analyzer provides VCO 2 values continuously. Combined gas exchange and pulse wave monitoring might be a valuable and a useful approach to detect AM in trauma patients.
section_name: P306 Oxygen delivery to carbon dioxide production ratio for continuously detecting anaerobic metabolism in trauma patients

section_content: Passive leg raising-induced changes in mean radial artery pressure can be used to assess preload dependence No change in heart rate and systemic vascular resistance was observed. We found a significant correlation between PLRinduced changes in COtd versus SVV during baseline (slope = 0. 902, P = 0. 003), changes in MAP (slope = 0. 499, P = 0. 003), PP (slope = 0. 190, P = 0. 024) and SP (slope = 0. 276, P = 0. 021). Changes in CVP were not correlated to changes in COtd. The area under the receiver operating curves was larger than 0. 7 but not different for MAP, PP, SP and SVV. Conclusion Not only baseline SVV but also PLR-induced changes in MAP, PP and SP are reliable parameters to assess preload dependence in cardiac surgery patients. In the clinical setting we prefer the MAP approach, based on simplicity, availability and robustness. The same data where collected before and after a RFL performed with 3 ml/kg hydroxyethyl starch 6%. The relationships between ∆SVI induced by SCD and ∆SVI induced by RFL were analyzed by linear regression analysis. Statistical significance was considered to be at P <0. 05.
section_name: P307

section_content: Results Linear regression analysis between ∆SVI induced by SCD (∆SCD) and ∆SVI induced by RFL (∆RFL) showed r 2 = 0. 50 (P = 0. 0002). When analyzed in a subgroup of spontaneously breathing versus mechanically ventilated patients, the relationships observed were respectively r 2 = 0. 41 (P < 0. 01) (Figure 1 ) and r 2 = 0. 73 (P < 0. 007) (Figure 2 ).
section_name: P308 Pulse pressure variation and adrenal insufficiency in septic shock

section_content: A Bisoffi Varani 1, A Martini 1, N Menestrina 2, A Russo 3, L Gottin Introduction Goal-directed intraoperative fluid therapy reduced the hospital stay after major surgery [1]. Aortic vascular surgery is associated with excessive blood loss and massive fluid shift [2]. We found that postoperative urea and creatinine improved when intravascular fluid volume was maintained using transoesophageal Doppler. Methods We randomly selected 40 patients who underwent elective infrarenal aortic surgery (aortic aneurysm repair/aortobifemoral grafting). All patients' cardiac output was continuously monitored using a transoesophageal Doppler probe (EDM™; Deltex Medical, Inc., Irving, TX, USA). The corrected flow time (FTc) was recorded immediately after induction as a baseline and recorded again pre-extubation. A target FTc of 375-425 ms was aimed for. The estimated total blood loss was calculated for each patient at the end of surgery. Preoperative and 24-hour postoperative urea and creatinine were recorded for comparison.
section_name: P311 Assessing fluid responsiveness in patients undergoing abdominal major surgery: a comparison of the respiratory systolic variation test and other indices

section_content: The mean baseline FTc was 278 ms, and the mean target FTc was 405 ms. The mean average blood loss was 3. 77 l/patient. The mean preoperative urea and creatinine were 5. 9 mmol/l and 95. 3mmol/l, respectively. The mean 24-hour postoperative urea and creatinine were 5. 23 mmol/l and 76. 77 mmol/l, respectively. See Introduction New information is emerging as a basis for reconsidering albumin as a key homeostatic molecule in the critically ill. We are only beginning to understand the full spectrum of albumin properties and action in healthy individuals and hypoalbuminaemic patients. Besides its function in the regulation of colloidal osmotic pressure, albumin has an important antioxidant capacity and a role in the transport of a wide range of drugs, hormones, ions, amino acids, and fatty acids. Few comparative studies have as yet been performed, and they address only a restricted number of parameters mostly defined by the European Pharmacopeia. 

Objective To study and compare the main albumin functions of eight preparations of pharmaceutical-grade albumin, using a battery of different techniques. Two additional albumin preparations, a preparation without stabilisers and a recombinant albumin from Pichia pastoris, were also included in the study.
section_name: Results

section_content: The following biochemical and physicochemical parameters were investigated: total protein concentration (Biuret assay) and albumin antigen (nephelometry); quantitative analysis of contaminating proteins by nephelometry, levels of polymers and fragments by gel filtration chromatography on Superose 6, the binding affinity of exogenous ligands for Sudlow's site I (warfarin) or site II (dansylsarcosine) by steady-state spectrofluorimetry, the reactivity of Cys34 with Ellman's reagent, and the esterase-like activity using p-nitrophenyl acetate as substrate by spectrophotometry. 

Results All pharmaceutical-grade products show a purity ranging from 95% to 108%. The main contaminant proteins are prealbumin, transferrin, α-1 acid glycoprotein, haptoglobulin, and retinol-binding protein. All of them are in conformity with the European Pharmacopeia specifications. The warfarin-binding capacity of the 10 albumin preparations was studied. An average binding constant of 2. 6 (±0. 3) x 10 5 M -1 (n = 1) was found. The presence of stabilisers reduced the binding of dansylsarcosine significantly (by 27-40%). The esterase-like activity toward pnitrophenyl acetate and the reactivity of Cys34 differed from product to product. Interesting is the absence of free Cys34 in the recombinant albumin. Conclusion Significant differences were observed between the 10 different human albumin preparations, recombinant or not. We confirm that the presence of stabilisers such as tryptophan derivatives significantly reduces the binding capacity of Sudlow's site II. Two important physiological properties of albumin, the esterase-like and antioxidant activities, were also found to be modified to different extents in all pharmaceutical-grade products in comparison with the albumin without stabiliser. The benefits of albumin administration should be considered carefully, taking into account the different functions and properties of albumin.
section_name: Methods

section_content: A Introduction Postoperative outcomes may be improved if cardiac output and oxygen delivery are maintained at optimal levels. Trials of the use of dopexamine for this purpose have yielded inconsistent results. This may relate to the use of high doses in some trials. A meta-analysis of data from these trials may therefore identify a benefit of low-dose dopexamine on postoperative mortality and length of stay. Methods A comprehensive literature review was performed to identify published randomised trials of perioperative dopexamine infusion in patients undergoing major surgery. Individual patient S129 data were obtained, allowing a meta-regression approach to explore mortality outcomes after correction for age and dose of dopexamine. A Cox proportional hazards model was constructed to examine the length of stay. Results Five studies fulfilled the inclusion criteria [1] [2] [3] [4] [5]. Low-dose dopexamine (≤1 µg/kg/min) was associated with a 49% reduction in 28-day mortality (6. 3% vs 12. 3%; OR = 0. 51 (95% CI 0. 29-0. 89), P = 0. 008). The length of postoperative stay was also reduced in the low-dose dopexamine group compared with control (median 13 vs 15 days, HR 0. 75 (95% CI 0. 65-0. 88), P = 0. 004). High-dose dopexamine (>1 µg/kg/min) was not associated with a difference in mortality (14. 5% vs 12. 3%; OR = 1. 18 (95% CI 0. 67-2. 08), P = 0. 37) or length of stay (median 17 vs 15 days, HR 1. 10 (95% CI 0. 90-1. 34), P = 0. 37) when compared with controls. The blood pressure waveform carries information about the cardiac contraction and the impedance characteristics of the vascular bed. Here, we demonstrate that the start of isovolumic ventricular contraction is persistently reflected as an inflection point in the pressure wave as recorded in the aortic root (TPIC) as well as in the carotid artery distension waveform (TDIC) as it travels down the arterial tree. In a group of six patients with normal pressure gradients across the aortic valve after valve replacement, the TPIC had a small delay with respect to the onset of isovolumic ventricular contraction (<10 ms). In a group (n = 21) of young, presumably healthy, volunteers, the inflection point occurred persistently in the carotid distension waveform, as recorded by means of ultrasound, before the systolic foot (intersubject delay between inflection point and systolic foot: mean ± SD = 40. 0 ± 9. 4 ms, intrasubject SD 4. 6 ms). Retrograde coronary blood flow during isovolumic ventricular contraction may be the origin of the persistent end-diastolic pressure and distension perturbation. This study shows that the duration of the isovolumic contraction can be reliably extracted from the carotid artery distension waveform. Discussion The requirement for ITU admission in this surgical group is, and has remained, low, despite a significant increase in bariatric surgical procedures. This increase is predominantly laparoscopic surgery. HDU activity has increased as the service has expanded; however, 90. 4% of this is level 1 care, particularly at TH, where admission to the HDU is a matter of policy rather than clinical necessity. Availability of a level 1 facility would significantly decrease the requirement for HDU provision -an important consideration when introducing a new bariatric service. Available online http://ccforum. com/supplements/11/S2
section_name: P314 Saline-induced hyperchloraemic metabolic acidosis: an unrecognised phenomenon among medical staff?

section_name: P315 An individual patient meta-analysis of clinical trials using dopexamine to increase oxygen delivery in high-risk surgical patients

section_name: Conclusions

section_name: P316 The onset of ventricular isovolumetric contraction as reflected in the carotid artery distension waveform M van

section_name: Introduction

section_name: P318 Intrathoracic pressure effects on hepatic flow and inferior vena cava diameter: an ultrasonographic study

section_content: Patients and methods Ten healthy subjects (seven females, three males; age 27. 3 ± 4. 5 years) were investigated in a supine position before and after application of continuous positive airways pressure (CPAP) of 10 cmH 2 O by nasal mask. The study was performed using sonographic equipment with a multiprobe (convex 3. 5-5 MHz; sector 2. 5-3. 5 MHz) and color-Doppler capability (Hitachi H 21). IVC was visualized by a two-dimensional echographic sector probe and M-mode was used to measure the inspiratory and expiratory diameters at the origin of the suprahepatic veins. HF is composed of portal flow (PF) and hepatic artery flow (HAF). Portal velocity, assessed near the liver hilum, was used as a measure of PF, and the left intrahepatic branch resistivity index (RI) was used as a measure of HAF. Measures were repeated twice for each value of intrathoracic pressure by two different examiners and the mean value was given for the statistical analysis. Results are given as the mean ± SD. Data were evaluated by paired t test and P < 0. 05 was taken as statistically significant. 

Results CPAP determined a reduction of portal vein velocity: 30. 0 ± 9. 1 cm/s vs 19. 7 ± 5. 0 cm/s (P = 0. 01). IVC diameters are increased by CPAP: inspiratory diameter 9. 49 ± 2. 5 cm vs 12. 05 ± 3. 9 cm (P = 0. 002), expiratory diameter 16. 46 ± 2. 9 cm vs 18. 08 ± 3. 65 cm (P = 0. 05).
section_name: Figure 1 (abstract P316)

section_content: The results of this study demonstrate that, in healthy subjects, variation of intrathoracic pressure by CPAP influences venous return. HF reduction could be due to an increased IVC pressure, as displayed by the bigger diameters measured during CPAP, other than a diaphragmatic descent. Ultrasonography is able to detect this effect and could be useful in a more complete evaluation of patient haemodynamic status in various clinical settings.
section_name: Conclusions

section_content: A Reintam 1, P Parm 2, R Kitus 2, H Kern 3, J Starkopf 2 1 East Tallinn Central Hospital, Tallinn, Estonia; 2 Tartu University Clinics, Tartu, Estonia; 3 DRK Kliniken Berlin, Germany Critical Care 2007, 11(Suppl 2):P319 (doi: 10. 1186/cc5479) Introduction Critically ill patients with severe sepsis or septic shock have a very high mortality rate. The aim of our study was to investigate the impact of intra-abdominal hypertension (IAH) on the outcome of patients with or without severe sepsis/septic shock. Methods Two hundred and fifty-three mechanically ventilated patients admitted to the general ICU of Tartu University Hospital were prospectively studied. Patients who had severe sepsis or septic shock at admission or developed it during their first week of stay were compared with patients not suffering from severe sepsis. IAH was defined as sustained intra-abdominal pressure above or equal to 12 mmHg developing within the first week in the ICU. Results Severe sepsis or septic shock was observed in 123 patients (48. 6%). The ICU mortality among these patients was 33. 3% compared with 18. 5% in nonseptic patients (P = 0. 005). IAH developed in 95 patients (37. 0%). The incidence of IAH was higher among septic patients (45. 5% vs 28. 5%, P = 0. 004). Those septic patients who developed IAH had a mortality rate of 50. 0% compared with 19. 4% in septic patients without IAH (P < 0. 001). Mortality among nonseptic patients was not different between the patients with or without IAH (18. 9% vs 18. 3%). Development of IAH was a significant risk factor for death in septic patients (OR 4. 15; 95% CI 1. 87-9. 26), but not in nonseptic patients (OR 1. 04; 95% CI 0. 39-2. 77). The abdominal pressure-volume relation can be described by a linear relation giving an elastance (E) and a pressure at zero volume (P V0 ). The goal of this study was to measure this relation in a large group of patients with different characteristics looking for the factors that influence and explain this relation. It is believed that obese persons have higher abdominal pressures and it is unclear whether muscle relaxation lowers it. A large group of 70 patients, ASA class I or II, between 21 and 75 years old and scheduled for laparoscopic surgery were included in this study with approval from the hospital ethical committee. Anaesthesia was induced with propofol 200 mg, sufentanil 20 µg, and sevoflurane 1. 5 Mac in 50% O 2 /N 2 O. Some patients were fully muscle relaxed with nimbex 20 mg while others not. Patients were asked to empty the bladder before surgery. The stomach was emptied by suction through a gastric tube. An Olympus insufflator UHI-3 was initialised and the abdomen was inflated with a stepwise flow to 7, 10, 13 and 16 mmHg. When the pressure was reached, flow was stopped and the actual pressure and volume measured giving four data points. E and P V0 were calculated by fitting to a linear relation. The following recorded determinants were evaluated by regression analysis for their effect: age, length, weight, BMI, sex, gravidity and muscle relaxation. P V0 increases significantly with body weight and decreases significantly with muscle relaxation.
section_name: P319 Intra-abdominal hypertension as a risk factor of death in patients with severe sepsis or septic shock

section_name: Conclusion

section_content: We evaluated the time course and relationship of proinflammatory cytokines and procalcitonin (PCT) serum levels after cardiopulmonary resuscitation (CPR). We hypothesized that an increase of cytokine levels would precede a marked increase in PCT levels and that PCT would be the best predictor of the final neurologic outcome. Methods Data were prospectively collected from 71 patients. Blood samples were taken after admission to the hospital and after 6, 12, 24, 72 and 120 hours. PCT, IL-6, IL-8 and TNFα levels were measured using automated assays. On day 14 patients were divided into two neurologic outcome groups according to the Cerebral Performance Categories (CPC 1-3: bad; CPC 4-5: good). Differences between groups were evaluated using a t test. 

ROC curves were computed to analyze the predictive value of the markers for a bad outcome.
section_name: Introduction

section_content: There was an early and significant increase in TNFα, IL-6 and IL-8 after admission to the hospital (14. 4 ± 5. 2, 185 ± 248 and 89 ± 81 µg/l) and in the ensuing 6 hours (15. 6 ± 8. 7, 209 ± 239 and 176 ± 232 µg/l) in patients with bad neurologic outcome. Initially, PCT levels were indistinguishable between the groups; however, a striking increase was observed in patients with bad neurologic outcome peaking after 24 hours (16. 7 ± 30. 0 vs 6. 9 ± 2. 1 µg/l; P < 0. 013). PCT values after 24 hours were the best predictor for a bad neurologic outcome with an area under the curve of 0. 91 (cutoff value: 0. 44; sensitivity 100%/specificity 62%). Conclusion TNFα, IL-6 and IL-8 serum levels are significantly elevated in the early phase after successful CPR in patients with bad neurological outcome. PCT increases are subsequently found and have a high prognostic value for the neurologic outcome.
section_name: Results

section_content: M Skrifvars 1, M Castrén 2, J Nurmi 2, A Thorén 3, S Aune 3, J Herlitz This pilot study assessed the effect of forced convective head and neck cooling on brain temperature, measured by magnetic resonance spectroscopy (MRS), in five healthy adult humans (three males). Following a 10-minute baseline, subjects received 30 minutes head cooling followed by 30 minutes head and neck cooling. The cooling device delivered air at 11ºC and 15 m/s through a hood and separate neck collar made of a double layer of nylon sheeting, the inner layer pierced with holes. Subjects wore a windproof waistcoat taped round the base of their neck and were wrapped in blankets from the base of the neck down. Bilateral foot warming with chemical hot packs was used to encourage heat loss in the presence of normothermia. MRS temperature data were collected at the level of the basal ganglia over the baseline and the last 10 minutes of each cooling intervention. MRS detects naturally occurring brain metabolites and interpretation of the relative frequencies of N-acetyl aspartate and water allows estimation of tissue temperature in 1 cm 3 voxels. For assessment of regional cooling, voxels lying within the region formed by joining the tips of the lateral ventricles were defined as 'core', voxels within approximately one voxel of the brain surface were defined as 'outer', and all other voxels were defined as 'intermediate'. The oesophageal temperature was measured continuously with a fluoroptic thermometer. The mean baseline-corrected MRS brain temperature over all voxels reduced by -0. 45ºC (SD 0. 23ºC, P = 0. 01, 5% CI -0. 74 to -0. 17ºC) with head cooling and -0. 37ºC (SD 0. 30ºC, P = 0. 049, 95% CI -0. 74 to 0. 00ºC) with head and neck cooling. Head cooling reduced the mean baseline-corrected MRS brain temperature in core voxels in all subjects. The formal test for gradient was not significant (P = 0. 43; 95% CI -0. 15 to 0. 29ºC). Head and neck cooling reduced the temperature in core voxels in three subjects; the test for gradient was not significant (P = 0. 07; 95% CI -0. 03 to 0. 58ºC). The mean baseline-corrected oesophageal temperature reductions for the last 10 minutes of each intervention were -0. 16ºC (SD 0. 04ºC) with head cooling and -0. 36ºC (SD 0. 12ºC) with head and neck cooling. Forced convective head cooling reduced the MRS brain temperature at an equivalent of 1. 35ºC per hour in healthy subjects, and the reduction was apparent across the brain.
section_name: P326 Do patient characteristics or factors at resuscitation influence long-term outcome in patients surviving to be discharged following inhospital cardiac arrest?

section_name: P332

section_content: The average temperature at admission did not differ in both groups (35. 5 ± 0. 9°C vs 35. 89 ± 0. 8°C). In the group with initial cooling by means of 4°C cold infusions, a significant temperature decrease could be reached during the invasive coronary diagnostics to admission to the ICU of an average 0. 84°C (35. 88 ± 0. 9°C vs 35. 04 ± 0. 9°C, P < 0. 0001). The middle chill duration up to the achievement of the target temperature after admission was significantly shorter with the combined method (341 ± 113 min versus 553 ± 342 min, P < 0. 01). The period to the achievement of the target temperature after the beginning of the external cooling device with the group of the combined method was significantly shorter (163 ± 91 min versus 342 ± 258 min, P < 0. 01).
section_name: Results

section_content: The combined method with initial cooling with 4°C cold solutions shows a sure and actual prestationary cooling procedure to the introduction or realisation of mild hypothermia and offers the possibility to reach the purpose temperature significantly faster. Preclinical introduction of mild hypothermia by means of 4°C cold solutions could be a beneficial criteria in the future treatment, and probably affects the outcome of these patients. Introduction Therapeutic hypothermia (TH) following cardiac arrest is associated with several complications including symptomatic bradycardia, coagulopathy, and pneumonia [1]. Furthermore, hyperthermia is associated with poor outcome following brain injury. The incidence of these complications may be increased by excessive temperature fluctuations. We sought to compare complications between two techniques used to induce TH; surface cooling (SC) using ice packs, and endovascular cooling (EV), using the Coolgard™ system (Alsius Corp., USA). Methods A retrospective review was performed of all cardiac arrest patients undergoing TH and surviving ≥48 hours between June 2005 and November 2006. Results Thirty-five patients underwent our TH protocol (SC group = 21, EV group = 14). The incidence of overcooling (<32°C) in the SC group was significantly higher than the EV group (10 vs 1, P = 0. 01), whilst a trend towards more episodes of symptomatic bradycardia (SC 9 vs EV 2, P = 0. 07) and rebound hyperthermia (SC 9 vs EV 2, P = 0. 07) was also present. The incidence of pneumonia (SC 7 vs EV 4, P = 0. 77) and coagulopathy/bleeding (SC 2 vs EV 3, P = 0. 32) were similar between groups. Conclusions (1) SC is associated with a significantly higher incidence of overcooling than EC and may be associated with an increase in complications such as symptomatic bradycardia. ( 2 ) SC may also be associated with an increase in rebound hyperthermia. An increase in oxygen consumption more than 25% of baseline identified the shivering threshold. Sedation was evaluated using the Observer's Assessment Sedation/Alertness scale. Two-way repeated-measures analysis of variance was used to identify interactions between drugs. Data are presented as means ± SDs; P < 0. 05 was statistically significant.
section_name: Conclusions

section_name: P333 A comparison of complications during therapeutic hypothermia between surface cooling and endovascular cooling techniques P Hayden

section_content: The shivering thresholds were 36. 4 ± 0. 5°C on the control day; 34. 9 ± 0. 6°C (P < 0. 01 from control) on the buspirone only day; 36. 1 ± 0. 6°C (P < 0. 01 from control) on the dexmedetomidine only day; and 34. 2 ± 0. 5°C (P < 0. 01 from control) on the combined buspirone and dexmedetomidine day. The calculated mean difference between the thresholds on the combined and the control days was 1. 9 ± 0. 4°C, while the measured mean difference derived from the difference between the combined and control days was 2. 3 ± 0. 4°C. There was only trivial sedation with either drug alone or in combination. The respiratory rate and end-tidal PCO 2 were well preserved on all days. Conclusion Buspirone and dexmedetomidine act synergistically to reduce the shivering threshold with only mild sedation and no respiratory depression. This combination might be a valid treatment to prevent shivering in stroke patients during therapeutic hypothermia.
section_name: Results

section_name: P335 Bispectral index and suppression ratio are very early predictors of neurological outcome during therapeutic hypothermia after cardiac arrest

section_content: Introduction Recently, the medical treatment in acute stroke has been making rapid progress. Especially, in the ischemic stroke of acute stage, the efficacy of thrombolysis, systemic t-PA or local transarterial urokinase infusion has been proved. However, the effective treatment time is still quite limited. The patients must be brought to the stroke center as soon as possible. We analyzed the reason why most stroke patients delay coming to the stroke center. 

We extracted the problems and proposed some solutions. Results Two hundred and forty-one patients (21. 7%) were hospitalized within 3 hours from the onset, and 365 patients (32. 9%) were within 6 hours. Among them, only 438 were admitted by ambulance. We found the following results. The main reason for the delayed admission is through another hospital, not a stroke center. The patients denied their symptoms are not so rare. The patients or their family often hesitate to request the emergency car. Conclusions The most significance point for rapid diagnosis and therapy is that people must doubt 'stroke' at first. We should further educate citizens to the warning signs of stroke and also the necessity of emergency admission using an emergency car. In addition, we should justly build a core stroke center in the district and centralize the patients. In each patient, measurements of V max, V mean and V min were performed at four different pump settings: without support (WS), and at pump assist pulse with ratio 1:1, 1:2 and 1:3. Results Repeated-measures analysis of variance: P = 0. 0006, considered extremely significant variation of TCD measurements among IABP settings. Comparing all pairs of V max, V mean and V min values, we found that V max and especially V mean are significantly greater at the 1:2 and 1:3 pump settings, but not at the 1:1 setting. We also found that the end diastolic velocities (V min ) were significant lower during the pump deflation. None of our patients had a significant diastolic flow velocity reversal during the pump deflation. Conclusions Left ventricular support with IABP significantly changed the flow velocity pattern of our patients. The pump significantly increased the V max and the V mean at the 1:2 and 1:3 settings because of pump inflation during the diastole. We suggest that the velocities did not change at the 1:1 setting because the end-diastolic flow velocities reduce during every pulse, according to pump deflation.
section_name: P340 Maintenance of prehospital medical systems due to clinical advance in acute stroke

section_name: Patients and methods

section_name: P341 Effects of intraaortic balloon counterpulsation on middle cerebral artery blood flow velocities

section_content: Neuromuscular dysfunction acquired during critical illness: a systematic review CIPM had a higher admission APACHE II score (18. 9 ± 6. 6 vs 15. 6 ± 6. 4, P = 0. 004) and SOFA score (8. 4 ± 2. 9 vs 7. 1 ± 2. 9, P = 0. 013). Multivariate logistic regression analysis showed that risk factors independently associated with the development of CIPM were severity of illness at the time of admission to the ICU, administration of aminoglycoside antibiotics and high blood glucose levels. Analysis according to severity of illness stratification revealed the emergence of Gram-negative bacteremia as the most important independent predisposing factor for CIPM development in less severely ill patients. Conclusions CIPM has a high incidence in the ICU setting. Our study revealed the important association that Gram-negative bacteremia, aminoglycosides, hyperglycemia and severity of illness have with CIPM development.
section_name: P342

section_name: P344 Interhospital cooperation after critical and emergency care for patients with cervical-thoracic-abdominal trauma and emergency diseases in the local medical area in a typical urban city of Japan

section_content: We examined interhospital cooperation after critical and emergency care for life-threatening cervicalthoracic-abdominal trauma (n = 501) and thoracoabdominal emergency diseases (n = 236) who were treated with intensive care in our CCEC and were able to be discharged or transferred to another acute treatment hospital.
section_name: Subjects and methods

section_content: Of the trauma patients directly transferred to our center, 48% were transferred to the 'affiliated hospitals', whose medical staffs were dispatched from the 'departments' in our university, 17% were transferred to the nonaffiliated hospitals, and 34% were directly discharged from our center. Of emergency disease patients, 28% were transferred to the affiliated hospitals, 20% were transferred to other hospitals, and 52% were directly discharged. Patients staying in our center for more than 14 days tended to be transferred to the affiliated hospital. Of trauma patients indirectly transferred from other hospital to our center, 30% and 11% were transferred to the affiliated and nonaffiliated hospitals, and 19% were directly discharged. Of emergency disease patients, these values were 21%, 7%, and 13%, respectively. Patients staying in our center for more than 14 days tended to be transferred to the affiliated hospital. Discussion and conclusion These results are thought to be a common situation in a typical urban city in the world. Now, the interhospital cooperation between city hospital and referral hospital does not function well because of poor understanding of retransfer to the previous hospital, resulting in dysfunction of the management of critical patients in the local medical area. It is important to construct a new interhospital-cooperation system based on the local medical area.
section_name: Results

section_content: The objective was to determine the relationship of early hypothermia to multiple organ failure and mortality in severely injured trauma patients. Methods This prospective observational study was performed at seven Level I trauma centers over 16 months. Severely injured patients with hypoperfusion and a need for blood transfusion during the early hospital course were followed with near-infrared spectroscopy-derived tissue oxygen saturation (StO 2 ) and clinical variables. Outcomes including multiple organ dysfunction syndrome (MODS) and 28-day mortality were evaluated. Hypothermia was defined as temperature < 35°C within the first 6 hours. 

Results Hypothermia was common (43%, 155/359). Hypothermic patients were more likely than normothermic patients to develop MODS (21% vs 9%, P = 0. 003), but did not have increased mortality rates (16% vs 12%, P = 0. 28). The maximum base deficit (Max BD) in hypothermic patients did not discriminate between those who did or did not develop MODS (9. 8 ± 4. 6 mEq/l vs 9. 4 ± 4. 4 mEq/l, P = 0. 56) but had good discrimination for mortality in both hypothermic and normothermic patients. Significant predictors of MODS using multivariate analysis included minimum StO 2 (P = 0. 0002) and hypothermia (P = 0. 01), but not Max BD (P = 0. 09). Predictors for mortality with multivariate analysis included minimum StO 2 (P = 0. 0004) and Max BD (P = 0. 01), but not hypothermia (P = 0. 74). Hypothermia remained a significant risk factor for MODS when fluid/blood infusion volumes were included in the multivariate model. Conclusions Hypothermia is common in severely injured trauma patients and is a risk factor for MODS but not mortality. Minimum StO 2 predicts MODS and mortality in normothermic and hypothermic patients, while the predictive effect of BD for MODS is blunted in the presence of hypothermia.
section_name: Introduction

section_content: The nonlactate gap: a novel predictor of organ failure and mortality following major trauma were measured on admission. We derived the calculated ion gap using a simplified Stewart-Figge equation, and subtracted the measured serum lactate from the calculated ion gap to obtain the nonlactate gap (NLG). 

Results See Table 1. The NLG discriminated survivors from nonsurvivors (P = 0. 008, analysis of variance). An NLG above 2 mmol/l was associated with an increased risk of mortality (P = 0. 010, Fisher's exact test). No patient with an NLG less than 2 mmol/l died; 32. 4% of the patients with an NLG above 2 mmol/l died. A NLG above 2 mmol/l also correlated strongly with organ failure (Multiple Organ Dysfunction Syndrome score P = 0. 011, Sequential Organ Failure Assessment score P = 0. 011, Mann-Whitney U test).
section_name: P346

section_content: We describe the NLG for the first time, and quantify it using simple bedside calculations derived from routine blood investigations. The NLG is an excellent marker for organ failure and death following major injury, and should be used to guide trauma resuscitation. Objective Outcome following major injury is time dependent. Early identification of high-risk patients allows rapid decision-making and correction of life-threatening disorders. Complex scoring systems are of limited value during major trauma resuscitation. Our aim was to evaluate the utility of a single blood pressure during the prehospital phase in combination with the blood pressure on arrival at the emergency department. Methods Data were collected prospectively on 1,111 patients admitted to a Level 1 South African trauma unit over a 1-year period. Patients were subdivided into two groups according to the combination of their prehospital (PH) and emergency department (ED) blood pressure. Hypotension was defined as a systolic blood pressure less than 90 mmHg. Mortality was defined as death within 30 days.
section_name: Conclusions

section_name: P347 Prehospital hypotension that persists on arrival at

section_content: The mortality in patients (n = 1,031) with normal PH and ED blood pressure was 5. 4%. The mortality in patients (n = 80) with PH and ED hypotension was significantly higher at 45% (P < 0. 0001, chi-square test) (Table 1 ).
section_name: Results

section_content: The combination of prehospital and emergency department systolic blood pressure is a simple yet extremely powerful predictor of mortality following major trauma and should be used as a triage tool to rapidly identify the highest risk patients.
section_name: Conclusion

section_name: P348 Traumatic cardiac injury in chest trauma

section_content: extravasation site computed tomography (CT). In this study we investigated the site and extent of contrast medium extravasation on CT findings and its effect on treatment and predicting clinical outcome in trauma patients. Methods Fifty patients admitted to our emergency department with blunt abdominal trauma showing contrast medium extravasation on abdominal-pelvic CT scan were included in our study for 33 months. Patients were prospectively collected and medical records were reviewed and analyzed retrospectively. The patients' clinical and laboratory findings, abdominal sonographic (FAST) findings, and CT findings were reviewed. Extravasation sites were classified as intraperitoneal, retroperitoneal, intrapelvic and correlated with post-treatment complications, mortality and morbidity rates.
section_name: S141

section_content: The incidence of extravasation site was intraperitoneal in 33 cases (66%), retroperitoneal in 13 cases (26%), and intrapelvic in four cases (8%). The frequency of injured vessels showing extravasation was 18 (36%) hepatic vessels, nine (18%) splenic vessels and six (12%) iliac vessels. There was no correlation between the extravasation site and ICU or total hospitalization duration (P > 0. 523). Sixteen patients with intraperitoneal extravasation required surgical intervention, six patients underwent angiography with embolization. In patients with retroperitoneal extravasation, nine were treated conservatively and two with embolization. Over all there were no significant differences between the extravasation site and treatment modality. The intraperitoneal group had the highest mortality with 13 deaths (11/33, 39%) and the highest early mortality rate (10/13, 76%) in the first 24 hours (P = 0. 001). Conclusion CT findings in patients with blunt abdominal trauma showed no significant correlation between the contrast medium extravasation site and treatment modality, ICU hospitalization duration, or final results. However, patients with intraperitoneal extravasation required more aggressive transfusion with packed red cells and had a higher mortality rate in the first 24 hours.
section_name: Results

section_content: Full-body low-dosage X-ray instead of single X-ray series in trauma: a preliminary experience report of a modified advanced trauma life support algorithm Introduction Patients presenting with trauma normally require resuscitation according to the advanced trauma life support (ATLS) algorithm. Techniques suggested during primary survey include Xray of C-spine, chest and pelvis. This can be time consuming and radiation intensive. In comparison with conventional multiple radiographs, Lodox (Statscan), a full-body digital radiology device, performs a. p. and lateral whole-body examinations in 3-5 minutes with about one-third of the irradiation and without the necessity for lifting patients. This is the first device installed in Europe. Methods This paper describes our experience with the use of a new low-dose X-ray technique as part of our modified ATLS algorithm, where single-total a. p. /lateral body radiographs have been implemented as adjuncts to primary survey in favour of several conventional X-rays. Results There were 94 patients (males = 59; females = 35) between 4 October and 9 December 2006; age range from 1 to 86 years. The ISS ranged from 3 to 75 (ISS > 16 in 54/94 patients). The average time for obtaining LODOX radiographs was 3. 5 minutes (range 3-6 min). The mean time in the resuscitation room (during primary and secondary surveys) was 28. 7 minutes with the new technique compared with 29 minutes before implementing LODOX (median time 27 min to 24 min). In 54/94 patients an additional full body CT scan was performed as adjunct to secondary survey. In only 14/54 patients were additional conventional X-rays necessary to visualize the skeleton.
section_name: P350

section_content: The implementation of a modified ATLS algorithm using LODOX allows a complete a. p. and lateral whole-body examination without a significant increase in the time taken for resuscitation. 

Since we are at the very beginning of a learning curve we are confident that in future the time for the ATLS primary survey can be markedly reduced. The LS imaging system seems to be a useful tool for rapid screening and management of trauma patients.
section_name: Conclusion

section_content: Peripheral oxygen extraction predicts organ failure and mortality following major trauma Methods A prospective, noninterventional study of 39 consecutive patients admitted to a Level 1 trauma unit ICU. Blood gas analysis was performed on samples from three locations: central venous line, peripheral venous line, and arterial line. Blood was drawn 6hourly in the first 24 hours, and oxygen extraction calculated using the Fick equation. Organ failure was assessed using MODS and SOFA scores. 

Results See Table 1. Peripheral, but not central, oxygen extraction with a threshold of 150 ml oxygen extracted per litre of blood distinguished survivors from nonsurvivors on admission to the trauma ICU. Low peripheral oxygen extraction (<150 ml) had an odds ratio for risk of death of 5. 3 (P = 0. 016, Fisher's exact test) and was associated with higher organ failure scores (P = 0. 044, Mann-Whitney U test). A trend of increasing peripheral oxygen extraction was also a strong predictor of mortality (P = 0. 019, Mann-Whitney U test) and organ failure (P = 0. 003, Mann-Whitney U test). Conclusions With an arterial and venous blood sample, and a simple equation, we have for the first time demonstrated that absolute and serial peripheral oxygen extraction are powerful predictors of organ failure and mortality following major injury.
section_name: P351

section_name: P352 Damage control orthopedics can improve outcome in trauma patients

section_content: We identified 48 patients, 24 for each group. The groups were comparable regarding all the considered parameters except for GCS at admission (group 1, 8. 63 ± 5. 12; group 2, 12. 2 ± 3. 99; P = and TRISS (group 1, 62. 04 ± 34. 55%; group 2, 82. 37 ± 18. 60%; P = 0. 01). We observed in group 2 a significant decrease of mortality (5 vs 0; P = 0. 02), incidence of ALI-ARDS (13 vs 4; P = 0. 01) and pneumonia (18 vs 6; P = 0. 01), a decrease of SOFA score (mean SOFA score: 7. 58 ± 4. 11 vs 3. 97 ± 2. 39, P < 0. 001; maximum SOFA score: 9. 83 ± 4. 36 vs 5. 62 ± 2. 97, P < 0. 001; days with SOFA >6: 3. 79 ± 3. 08 vs 2. 16 ± 2. 18, P = 0. 04).
section_name: Results

section_content: We observed an improvement of respiratory parameters and SOFA score in patients treated with DCO. Furthermore, patients with worse neurological conditions at admission do not undergo orthopaedic surgery because it could worsen the cerebral perfusion (risk related to transfer to a far operating room). The physician's decisions (and therefore the patient's prognosis), in our experience, are limited by access to optimal therapeutic solutions that could improve the clinical course of the patient.
section_name: Conclusions

section_content: A Di Filippo 1, S Damiani 1, M Migliaccio 1, M Bonizzoli 2, A Peris Introduction In a group of patients that evolved in brain death after head trauma, we evaluated the risk factors for an early brain death (in the first 3 days) among the parameters collected prehospital, in the emergency room (ER) and during the ICU stay. Method All the consecutive patients admitted to the ER of Careggi Hospital that evolved to brain death after head trauma during the period January 2004-June 2006 were considered (n = 54). The following parameters were considered for the study: prehospital phase: hypoxemia (SaO 2 < 95%), hypotension (SAPS II < 90 mmHg), orotracheal intubation, fluids (>1,000 or ≤1,000 ml), and GCS; ER phase (ATLS approach): hypoxemia, hypotension, orotracheal intubation, fluids, GCS, blood lactate, pharyngeal temperature, and ISS; ICU stay: SAPS II, daily SOFA score, blood lactate, core temperature, glycaemia, and ScVO 2 (>75% or ≤75%). On the basis of the timing of brain death, the patients were divided into two groups: group 1 (n = 27), brain death occurred in the first 3 days; group 2 (n = 27), brain death occurred in the days after. Statistics were determined with the Student t and chi-squared tests; P < 0. 05 was considered significant. 

Results The significant differences between the two groups are reported in Table 1. A strict relationship exists between early brain death and prehospital treatment. During the ICU stay low levels of ScVO 2 and high levels of glycaemia are related to early brain death.
section_name: P353 Head trauma: risk factors for early brain death -our experience

section_content: The results of the study confirm that prehospital hypotension is the main risk factor for an early evolution to brain death in head trauma. Also, patients that have prolonged hypoperfusion and neurohormonal imbalance after the postresuscitation phase present an increased risk of brain death.
section_name: Conclusion

section_content: Sensitivity and specificity of a triage score dedicated to trauma patients in a tertiary-level hospital: preliminary results Introduction The aim of the study was to determine the sensitivity and specificity of the triage criteria adopted for multiple trauma patients in order to activate the Trauma Team in our tertiary-level trauma centre. Methods A cohort study. Between 1 September and 30 November 2006, all trauma patients admitted to the ED triaged red, yellow or green on admission and discharged as a red code from the ED following specific criteria were included. Triage criteria on admission included at least one of the following: GCS < 13, systolic BP > 220 and < 100 mmHg, SaO 2 < 95% on oxygen 100% or intubated; clinical signs: penetrating wounds, spinal injury, sternal or flail chest, two long-bone fractures, proximal crash or amputation of limbs, post-traumatic seizures at any time, signs of fracture of the skull; major accident mechanics: fatality in the same vehicle, fall from a height > 3 m, prolonged extrication time (> 20 min), pedestrian hit by a car, ejection, explosion in a close environment. Severely injured patients at discharge from the ED were defined by: invasive resuscitating procedures (that is, tracheal intubation), invasive life-saving procedures (emergency surgery, defibrillation) and need for admission to the ICU. Sensitivity and specificity of the triage criteria assigned on admission were calculated and compared with the patients that were triaged red at discharge from ED.
section_name: P354

section_content: Results During the time span, 5,142 trauma patients were admitted to the ED: 4,884 were triaged green, 182 yellow and 76 were triaged as red. Of the 76 red on admission, 55 patients fulfilled the abovementioned criteria and were confirmed severely injured at discharge from ED. Out of the 55, 53 patients were S143 correctly identified by triage criteria, while two patients were missed. The sensitivity is 96%. Out of the 76 triaged red on admission, 53 patients were confirmed at discharge from ED. The specificity is 70%. Conclusions Even if major accident mechanics were included in the admission triage criteria, overtriage was limited to 30%. On the other hand, undertriage was approximate to zero, and the only two yellow codes missed were related to miscommunication by the prehospital team. Moreover, the conjunctiva receives blood from the internal carotid artery and the sublingual tissue receives from the external carotid artery. We hypothesized that conjunctival and sublingual microcirculation can be used to evaluate intracranial and extracranial perfusion and to monitor therapy to improve cerebral perfusion pressure in patients after head trauma. Methods In three groups of patients with increased intracranial pressure (ICP) (high ICP > 30, medium ICP 20-30 and low ICP < 20) following head trauma, both the conjunctival and sublingual microcirculation was measured using sidestream darkfield imaging (MicroScan ® ; MicroVision Medical, The Netherlands) to evaluate intracranial and extracranial perfusion. Using microvascular analysis software (MAS ® ; MicroVision Medical), functional density of small (<20 µm), medium (20-50 µm) and large (>50 µm) microvessels were determined in addition to erythrocyte velocities. Results Conjunctival microcirculatory flow was intermittent in patients with highest ICP, low-continuous in patients with medium ICP, and normal-continuous in patients with lowest ICP. Intracranial perfusion pressure was lowest in patients with highest ICP and vice versa. Functional vessel densities in the conjuctiva were in the same range in all three groups. However, the sublingual functional capillary densities were consistently lower in all groups as compared with controls, suggesting an active intracranial and extracranial regional autoregulation. Conclusion Conjunctival microcirculatory flow analysis reflects alterations in cranial perfusion pressure and might be a possible noninvasive endpoint to monitor cerebral perfusion and therapy.
section_name: P

section_name: P355

section_content: The influence of hypotensive resuscitation in hemorrhagic shock with coexisting severe head injury: an experimental protocol Retrograde catheterization of the internal jugular vein (SjO 2 ) and laparotomy was performed. A surgical knot 4 mm long was made at the aorta, with a 3. 0 diameter stitch. The abdomen was closed. Then a craniotomy and traumatic brain injury (TBI) was made. A regional cerebral blood flow catheter (RoCBF) was placed under the dura. After the TBI the intraabdominal hemorrhage was made by pulling the titch (rupture of the aorta). The animals were assigned into two groups: group A (fluid resuscitation) and group B (hypotensive resuscitation). The animals that survived after 1 hour of hemorrhage were managed by surgical checking and with 1 hour more of fluid resuscitation. 

Results See Table 1 : RoCBF and SjO 2 before and after the surgical checking of the hemorrhage.
section_name: P356

section_content: In group B there was complete restoration of cerebral blood flow and brain oxygenation, after the surgical checking of hemorrhage. Hypotensive resuscitation causes significant reduction in mortality in patients with closed intraabdominal trauma and coexisting head injury, without putting cerebral function in jeopardy. The intrinsic autoregulation mechanisms of the cerebral vessels that normally maintain a constant cerebral blood flow (CBF) relatively independently from the cerebral perfusion pressure variations are frequently impaired in the severely traumatized. It has been shown that hyperventilation can restore the cerebral autoregulation and controlling intracranial pressure, but much less attention has been given to the effects of the hyperoxic state in the restoration of cerebral autoregulation. The purpose of the study was to compare the autoregulatory response to hyperventilation vs hyperoxia in severe traumatic brain injury.
section_name: Conclusion

section_content: Available online http://ccforum. com/supplements/11/S2 We prospectively examined 186 (aged 34. 4 ± 14. 99 years) patients with severe traumatic brain injury (postresuscitation GCS 5. 98 ± 3. 0957) following admission to the neurosurgical ICU of a level one trauma hospital. Hyperventilation and hyperoxia studies were conducted, recording middle cerebral artery flow velocity and the autoregulation index (ARI) bilaterally and simultaneously at baseline and posthyperventilation (CO 2 reactivity = %∆CBF/ ∆pCO 2 )/hyperoxia (O 2 reactivity = ∆PbtO 2 /∆pO 2 ). Continuous multimodal neuromonitoring, intracranial pressure, mean arterial blood pressure, cerebral perfusion pressure, end-tidal CO 2 (ETCO 2 ), PbtiO 2, and SjvO 2, was recorded. The ARI (normal 5 ± 1) in these head-injured patients averaged 2. 2 ± 1. 5 on day 1 and gradually improved over the 10 days of monitoring. The ARI significantly improved with hyperoxemia, during the first 6 days after injury when compared with the ARI measured at normoxemia. The mean left ARI difference during hyperoxia was 0. 4069 ± 1. 7948 while the right ARI difference was 0. 4708 ± 1. 8413. The average change in pCO 2 during hyperoxia was 35. 6468 ± 5. 8778. These changes in the ARI during hyperoxia were smaller than those observed during hyperventilation. Hyperventilation increased the ARI by average 0. 8519 ± 0. 2310 on the left and 1. 0833 ± 0. 4654 on the right. Pressure autoregulation was impaired in these head-injured patients. Hyperoxia significantly improved pressure autoregulation. 

The very small change in pCO 2 induced by hyperoxia does not seem to explain this improvement in pressure autoregulation. Vasoconstriction induced by hyperoxia may partially contribute to the improved pressure autoregulation. ), CT-scan results, daily worst Glasgow Coma Scale score, and admission Simplified Acute Physiology Score II. We inserted an arterial catheter for invasive pressure monitoring, a central venous catheter and a unilateral jugular bulb in front of the most damaged brain hemisphere (cf. CT scan). Jugular bulb thrombosis was prevented by continuous infusion of 2 ml/hour isotonic serum without heparin. Blood samples were obtained simultaneously from the central venous line (K) and jugular bulb (B) at admission, 6 hours, 12 hours, and then in case of neurological aggravation or daily until 5 days. We measured the platelet count, prothrombin time (PT), activated partial thromboplastin time (ACT), fibrinogen concentration (Fib), prothrombin fraction 1+2 (F) and thrombinantithrombin complex (TAT). During the study only central venous blood samples (PT, ACT, Fib and platelet count) could be available if necessary. Otherwise blood samples were centrifuged and preserved refrigerated for post-hoc analysis. Statistical analysis was by Student's t test, paired t test for paired results and analysis of variance. Significance was set as P < 0. 05.
section_name: P357

section_name: P358 C1-inhibitor attenuates neurobehavioral deficits following controlled cortical impact brain injury in mice

section_content: The total n = 19; nine survivors (S) and 10 deaths (NS). 

No differences between S and NS in demographics, management modalities, admission GCS score (7 ± 3), CT scan, and SAPS II (27 ± 10 vs 30 ± 17, P = 0. 69). The B vs simultaneous K platelet count was significantly lower in all drawn blood samples, with a trend to decrease over time. S vs NS at day 2 and day 3: 191 ± 60 vs 125 ± 35 (P = 0. 017). The admission B thrombin fraction was higher in NS (1,000 ± 209 vs 460 ± 294, P = 0. 014). The B day 1 TAT was higher in NS: 45 ± 20 vs 9. 6 ± 12 (P = 0. 02). No Responses to these tests were compared between patients having received etomidate and those having received other induction agents. RAI was defined as an increase in cortisol levels <248. 4 nmol/l (9 µg/dl), measured 30 and 60 minutes after the ACTH test. Logistic and linear regression models were used to compare the two groups of patients on outcomes while taking confounding variables into account.
section_name: Results

section_content: Of the 94 patients eligible for this study, 40 (43%) gave consent for the ACTH test. Fifteen patients received etomidate and 25 received other induction agents. At 24 hours, there were no differences in the risk of RAI between groups (OR: 1. 8, 95% CI: 0. 2-14. 3, P = 0. 59). However, at 24 hours, subjects who had received etomidate presented a significantly lower response to ACTH (adjusted mean: 299. 7 nmol/l, 95% CI: 214. 7-384. 8 versus 503. 8 nmol/l, 95% CI: 441. 8-565. 7, P = 0. 002). At 48 and 168 hours, this difference disappeared. For all eligible patients (n = 94), there was a nonsignificant trend to an increased risk in mortality in the etomidate group (adjusted OR: 4. 8, 95% CI: 0. 6-35. 9, P = 0. 13). Etomidate was also associated with an increased risk of pneumonia (adjusted OR: 3. 0, 95% CI: 1. 0-8. 7). 

The adjusted length of stay in the ICU was not different between groups. At discharge, the adjusted motor Functional Independence Measure (FIM) score was significantly lower for subjects in the etomidate group (32 versus 56, P = 0. 002), but the adjusted cognitive FIM score was not significantly different in the etomidate group (35 versus 46, P = 0. 15). Conclusions These results suggest that etomidate decreases the adrenal reserve up to 24 hours after a single dose used for the intubation of traumatic brain injury victims. A larger randomized controlled trial is needed to further assess etomidate's impacts on morbidity and mortality. norepinephrine concentrations (10 nM to 100 µM); thrombin receptor activator peptide (TRAP) served as positive control.
section_name: Results

section_content: Results Following TBI, the number of unstimulated P-selectinpositive platelets was significantly decreased in the second week by 60%. During the first week, the in vitro stimulatory effect was significantly reduced; in the second week, however, norepinephrine-mediated effects exceeded changes in controls and the first week without a difference between arterial and jugular venous platelets (Figure 1 ). Conclusion Clinically relevant norepinephrine concentrations are <25 nM. The present in vitro effects occurred at concentrations >500 nM. Thus, a clinically relevant impact appears doubtful. Results One hundred (70%) patients were admitted after trauma, 15 (11%) after surgery, 27 (19%) had medical disease. The mean SAPS II score was 45 ± 15. 8 and the mean length of stay was 16 ± 9. 84 days. Forty-six patients (32. 4%) underwent major surgery following the admission. The overall prevalence of DVT was 17. 6% (25/142), with the highest value (24. 2%) in the 41-59 year group and the lowest (12. 5%) in the >75 year group. DVT was diagnosed in 12/25 (48%) patients within 48 hours from ICU admission and 7/12 (58. 3%) had direct venous injury. DVT was diagnosed in the remaining patients after 10 days. We found a strong relationship (P < 0. 06) between the length of stay and DVT in patients <40 years. No significant differences were found regarding SAPS. Conclusions In our experience, DVT prevalence showed a bimodal occurrence with a first short-term peak, associated with traumatic or surgical direct venous injury, and a medium-term peak, related to an ICU stay >10 days. We therefore oriented the surveillance to the two periods of higher DVT prevalence and we established a training program for the intensivists to improve DVT detection, relieving the workload of the ultrasound physician.
section_name: P-selectin expression was determined by flow cytometry (FACS).

section_name: P362

section_content: Venous thromboembolism in critically ill patients: incidence and risk factors Patients We enrolled consecutive patients >12 years of age expected to stay in the ICU >48 hours. We excluded patients on systemic anticoagulation and patients with pulmonary embolism (PE) or deep venous thrombosis (DVT) on admission to the ICU or diagnosed within 24 hours of ICU admission. We recorded a priori defined VTE risk factors at baseline and daily. Our ICU implements a protocol for thromboprophylaxis, which is based on the evidencebased ACCP guidelines. The primary endpoint was the development of PE or DVT during ICU stay. We used multivariate regression analysis to determine independent predictors of VTE. Results Among 277 patients with a mean APACHE II score of 25 (+9), the incidence of VTE was 7. 2% (95% CI 4. 5-11). We identified three independent risk factors for ICU-acquired venous thromboembolism: stroke (OR 13. 5, 95% CI 1. 9-91. 19, P = 0. 008), femur fracture (OR 4. 5, 95% CI 1. 18-17. 10, P = 0. 03), and ICU length of stay (OR for each day increment 1. 08, 95% CI 1. 03-1. 13, P = 0. 002). After adjustment for APACHE II score, VTE was an independent predictor of mortality (OR 3. 85, 95% CI 1. 11-13. 29, P = 0. 03). Conclusions VTE is relatively common complication in critically ill patients and is associated with significant mortality. Longer ICU length of stay, stroke and femur fracture are independent predictors for VTE. These findings suggest the need for more effective prophylactic strategies in critically ill patients, especially those at higher risk. Acknowledgement Sponsored by Sanofi-Aventis.
section_name: P363

section_content: Aalborg-Aarhus University Hospital, Aalborg, Denmark Critical Care 2007, 11(Suppl 2):P364 (doi: 10. 1186/cc5524) Introduction Treatment of acute pulmonary embolism (PE), which causes life-threatening cardiovascular collapse, consists of cardiopulmonary bypass (CPB) and surgical embolectomy. In the clinical practice we have treated three such patients successfully with CPB but instead of performing embolectomy, administered recombinant plasminogen activator (rt-PA). We studied the circulatory and respiratory effects of this combined therapy in a swine model of fatal PE. Methods Seven pigs (90 kg) were i. v. anesthetized, muscle relaxed, tracheally intubated and mechanically ventilated (FiO 2 1. 0). A large-bore catheter (8. 5 mm ID) was inserted in the right superior vena cava (for injection of preformed blood clots) and large-bore catheters were inserted in the inferior vena cava via the S147 femoral vein and in the aorta via the femoral artery (for accessing CPB). We measured the mean arterial pressure (MAP), cardiac output (CO), blood gases, pulmonary artery pressure measurement (MPAP), end-tidal CO 2 (ETCO 2 ) and blood gases. Then 100-300 ml preformed blood clot was injected until systemic circulation ceased (systolic AP < 25 mmHg) and a 5 minute interval was allowed before start of CPB (flow rate of 4-7 l/min). Heparin 10,000 IE was given i. v., and rt-PA 10 mg as an i. v. bolus followed by an i. v. infusion of 90 mg during 2 hours. If ventricular fibrillation occurred, cardioversion was performed. After 145 minutes CPB was weaned off, and after a further 40 minutes the experiment was ended. 

Results Five animals developed ventricular fibrillation, while one animal maintained sinus rhythm. After 2 hours all animals had an atrial rhythm.
section_name: P364 Cardiopulmonary bypass and recombinant plasminogen activator for treatment of experimental fatal pulmonary embolism B Kjaergaard, M Risom, S Risom Kristensen, E Tonnesen, A Larsson

section_name: P365 Early coagulation alterations in intensive care unit burn patients

section_content: The aim of the present study was to examine the coagulation status of patients in the early postburn period. Method Coagulation and fibrinolysis parameters -antithrombin III (ATIII), protein C (PrC), free protein S (PrS), plasminogen activator inhibitor 1 (PAI-1), tissue plasminogen activator (t-PA), thrombin/ antithrombin complexes (TAT), plasmin/α 2 -antiplasmin complexes (PAP), fibrin degradation products (F1. 2) -were measured at ICU admission and daily thereafter for 7 postburn days. Results Forty-five patients were screened (nine nonsurvivors and 36 survivors). All patients had a severe deficiency of the coagulation inhibitors on admission. Normalization of these levels in survivors was observed at day 5 for ATIII and PrC, and at day 7 for PrS. All patients had elevated levels of TAT during the investigation period, but survivors had significantly lower levels at day 7 postburn (6. 2 ± 4. 9 vs 11. 4 ± 4. 5 µg/l, P < 0. 001). PAP levels were within the physiological range in both groups at day 1, remained low in survivors, but raised significantly in nonsurvivors at day 7 (19. 3 ± 14 vs 80. 9 ± 10. 4 µg/l, P = 0. 003). The t-PA levels were elevated permanently only in nonsurvivors. PAI-1 levels were increased at day 1 in both groups, but returned to normal values at day 5 in survivors. The degree of PAI-1 activation was significantly higher than this of t-PA. The F1. 2 levels were permanently elevated and there was no statistically significant difference in both groups. 

A logistic regression analysis revealed that ATIII and PrS at days 3, 5 and 7, Pr C at days 5 and 7 and TAT at day 7 were independent predictors of ICU death.
section_name: Introduction

section_content: Our findings indicate the early postburn dysregulation of the hemostatic balance characterized by the activation of procoagulant pathways. Although fibrinolysis was activated, the inhibition of fibrinolysis was more pronounced at the same time. 

The coagulation inhibitors and TAT levels seem to be early predictors of ICU mortality.
section_name: Conclusion

section_content: Fibrinolysis during cardiopulmonary bypass detected with thromboelastography R Hájek, J Ruþ þiè èková, I Fluger, P Nemec, V Bruk University Hospital, Olomouc, Czech Republic Critical Care 2007, 11(Suppl 2):P366 (doi: 10. 1186/cc5526) Background Fibrinolysis is a common haemostatic abnormality during cardiopulmonary bypass (CPB). Thromboelastography (TEG) is a good method to detect both types of fibrinolysis. Methods Four hundred and ninety-nine patients during mild hypothermic CPB and elective surgery were monitored with TEG (first -after the induction, second -after rewarming, third and fourth -at the end of surgery native and heparinase). No prophylactic antifibrinolytics were used. The data of the study group were compared with a control group of 475 patients monitored only with laboratory tests (fibrin degradation products (FDP) and D-dimers). 

Peroperative and 24 hour postoperative bleeding, number of transfusions, aprotinin therapy and reexploration were recorded. 

Correlations between the presence of fibrinolysis and blood loss and transfusion therapy and between aprotinin administration and blood loss and number of transfusions were evaluated.
section_name: P366

section_content: The frequency of fibrinolysis measured with TEG: before surgery -primary 3. 2%/secondary 3. 4%; during CPB -18. 8%/ 0. 6%; after surgery -7%/1. 4% (native), 5. 6%/0. 6% (heparinase). Positivity of fibrinolysis detected with laboratory tests was 100%. 

The TEG parameter of fibrinolysis (LY30) was significantly increased during CPB. The frequency of aprotinin administration was 12% TEG, 10. 7% control. No correlation between positivity of fibrinolysis and peroperative/postoperative blood loss and red blood cells (RBC) and fresh frozen plasma (FFP) transfusions were recorded. No correlation between aprotinin administration and peroperative/postoperative blood loss and RBC transfusion were recorded. Positive correlation between aprotinin administration and FFP transfusion were recorded Conclusion Fibrinolysis was usually not associated with serious bleeding. There was no positive effect of aprotinin to reduce bleeding or transfusion therapy. FDP and D-dimers are not useful to detect fibrinolysis in cardiac surgery. Objective On-pump cardiac surgery is frequently associated with intraoperative and postoperative bleeding. ROTEM ® is a point-ofcare method that reflects more closely than classical coagulation tests the in vivo haemostatic activity and the contribution of fibrinogen and platelets to clot formation. Methods Two hundred and thirty-two patients (age 67 ± 10 years) with elective cardiac surgery and an on-pump time >45 minutes (mean 112 ± 52 min) were enrolled. Preoperative, intraoperative and postoperative blood samples were taken from an arterial catheter. The ROTEM ® system and test kits (INTEM/EXTEM = intrinsic/extrinsic activation, FIBTEM = EXTEM with inhibition of platelets) were from Pentapharm (Munich, Germany).
section_name: Results

section_name: P367 ROTEM ® thrombelastometry in on-pump cardiac surgery patients

section_content: The clot formation time (CFT) and maximum clot firmness (MCF), but not clotting time (CT), were strongly correlated with the fibrinogen level and platelet count. Surgery significantly decreased the ROTEM haemostatic activity, but normalised in most patients within 14-18 h postoperation. Lowest haemostatic activity (dramatic increase in CT and CFT, decrease in MCF) was seen when patients were conditioned for cardiopulmonary bypass (CPB). When connected to CPB, the CT and CFT turned to recover, but MCF in EXTEM remained unchanged and MCF in FIBTEM declined further indicating continuous fibrinogen consumption. In 12. 5% of our patients, postoperative MCF in FIBTEM was reduced to <9 mm indicating a need for fibrinogen substitution. Low postoperative activity in ROTEM ® was associated with high postoperative blood loss. The positive predictive value and specificity of FIBTEM were clearly superior to those of the APTT or prothrombin time. Up to 50% of patients had an increased haemostatic activity in preoperative ROTEM ®, and this was associated with high CRP levels and intraoperative blood loss. Conclusions ROTEM ® is a valuable tool to monitor perioperative haemostasis. The decreases in haemostatic activity and postoperative bleeding are probably due to anticoagulant therapy as well as fibrinogen and platelet consumption. An increased preoperative haemostatic activity is probably due to an acute phase reaction associated with advanced atherosclerosis, and the high intraoperative bleeding in these patients might be due to the atherosclerotic vessels rather than due to an insufficient haemostasis. Background Venous thromboembolism is one of the most common complications seen in cancer patients and may be due to the hypercoagulable state of the malignancy and to its surgical treatment. Despite clinical and laboratory evidence of perioperative hypercoagulability, there are no consistent data evaluating the extent, duration, and specific contribution of platelets and procoagulatory proteins by in vitro testing.
section_name: Results

section_name: P368

section_content: Co analyser) analysis (HVG), a viscoelastic test that measures clot formation and includes information on the cellular, as well as the plasmatic coagulation, system. We examined the efficacy of a variety of coagulation tests. A complete coagulation screen, activated clotting time, thromboelastography (TEG) and hemoviscoelastography (HVG) were performed before surgery, at the end of surgery, and on postoperative days 1, 2, 3, and 7; they were analyzed for the reaction time and the maximal amplitude (MA). We tested the hypothesis that the parallel use of standard TEG and HVG can assess postoperative hypercoagulability and can estimate the independent contribution of procoagulatory proteins and platelets.
section_name: Materials and methods Patients undergoing planned curative open surgery for abdominal cancer received MEDNORD (Ukraine

section_content: We calculated the elastic shear modulus of standard MA (Gt) and HVG MA (GH), which reflect the total clot strength and procoagulatory protein component, respectively. The difference was an estimate of the platelet component (Gp). There was a 14% perioperative increase of standard MA, corresponding to a 48% increase of Gt (P < 0. 05) and an 80-86% contribution of the calculated Gp to Gt. We conclude that serial standard TEG and the HVG viscoelastic test may reveal the independent contribution of platelets and procoagulatory proteins to clot strength. Using multiple linear regression, all coagulation, TEG and HVG variabilities were used to model postoperative hypercoagulation. Results showed that some components of the TEG failed to identify hypercoagulation (r < 0. 2, P > 0. 75). However, three components of the routine coagulation assay, including bleeding time, prothrombin time, and platelet count, could be modeled to show prolonged postoperative hypercoagulability (P < 0. 01). We conclude that all components of the HVG test reflect postoperative coagulopathies; these results suggest that it may be useful in determining the coagulation status of cancer patients perioperatively. Conclusion Postoperative hypercoagulability, occurring for at least 1 week after major cancer abdominal surgery, may be demonstrated by the HVG viscoelastic test. This hypercoagulability is not reflected completely by standard coagulation monitoring and TEG, and seems to be predominantly caused by increased platelet reactivity. The HVG viscoelastic test provides a fast and easy to perform bedside test to quantify in vitro hemocoagulation. Objective Cardiac surgery, in particular when done with cardiopulmonary bypass (CPB), is frequently associated with excessive intraoperative and postoperative bleeding. Here we employed the Technothrombin ® thrombin generation assay (TGA; Technoclone) to monitor changes in perioperative haemostasis. Methods One hundred and forty-eight patients (age 66. 0 ± 9. 8 years; 103 males, 45 females) with elective cardiac surgery and a CPB time >45 minutes (mean 114 ± 56 min) were enrolled. Arterial blood samples were obtained preoperative, postoperative and 14-18 hours postoperative and centrifuged within 30 minutes after withdrawal, for 5 minutes at 5,000 x g. Plasma samples were stored until analysis at -80°C. Thrombin generation (TG) induced by the TGA RC low reagent (71. 6 pM tissue factor) was measured in 96-well multiplates using a FLUOstar OPTIMA fluorescence reader (MWG Labtech).
section_name: Results and discussion

section_content: Results Due to cardiac surgery, the lag-phase and time-to-peak of TG increased by 45% and 35%, respectively. In parallel, the peak thrombin concentration and maximum slope decreased by 42% and 51%, respectively (P < 0. 000001). Both the lag-phase and time-to-peak returned to basal values within 14-18 hours postoperative, but the peak thrombin and maximum slope of TG rose above the preoperative values (+39% and +68%, P < 0. 0005). The on-pump time was positively correlated with lag phase and time to peak and negatively correlated with peak thrombin and maximum slope of TG when measured at 14-18 hours postoperative, but there was no correlation at early postoperative. With respect to classical coagulation parameters, significant correlations were observed between TG and activated partial thromboplastin time at preoperative and 14-18 hours postoperative, and between TG and prothrombin time at postoperative (P < 0. 025-0. 001). At 14-18 hours postoperative there was a significant correlation of TG with platelet as well as leukocyte counts (P < 0. 025).
section_name: P369

section_content: The data provide clear evidence for a marked decrease of TG during cardiac surgery followed by an excess restoration in the postoperative phase. Factors released from platelets and leukocytes (procoagulant microvesicles?) might contribute to the enhanced TG observed at 14-18 hours postoperative. Introduction Orgaran ® (danaparoid sodium) is a low-molecularweight, nonheparin glycosaminoglycan antithrombotic that is currently a first-line treatment for heparin-induced thrombocytopenia (HIT). This study reports on the safety of Orgaran ® in ICU patients suffering from HIT and acute renal failure requiring continuous renal replacement therapy (haemofiltration). Methods Data on 96 case reports from personal experience and publications have been collated.
section_name: Conclusions

section_name: P370

section_content: Nineteen females and 59 males (18 unknown gender) with a median age of 60 years (range 22-95 years) presented with a variety of clinical problems that either preceded or complicated their HIT; for example, postoperative/accidental trauma or overt bleeding in 61, sepsis/septicaemia/septic shock in 37, thromboembolism in 23, multiple organ dysfunction syndrome in 14, disseminated intravascular coagulation in eight and other miscellaneous serious problems in 38. 

A variety of continuous extracorporeal haemofiltration circuits was used for from 1 to 39 days (median 7 days). The Orgaran ® dosing schedule was usually initiated with a 2,000-2,500 U intravenous bolus injection. After two step-down dose periods the subsequent maintenance infusion was usually titrated according to each patient's thromboembolic and bleeding risk status. Hence most patients received 100-400 U/hour, but 11 patients required up to 600 U/hour temporarily to control extracorporeal circuit clotting. There were 12 minor bleeding events, occurring mostly during the maintenance infusion rate adjustment period and which responded to transient interruption and/or lowering of the infusion rate. Eleven nonfatal major bleeding events occurred (four due to procedural errors) and eight fatal major bleeds, two of which occurred 3 days and 8 days after Orgaran ® discontinuation. Plasma anti-FXa levels were reported for 38 patients. During seven of the eight fatal bleeding episodes the plasma anti-FXa levels were ≥0. 8 U/ml in three patients and 0. 31-0. 66 U/ml (that is, within the target range) in the other four patients. The highest anti-FXa response of 2. 00 U/ml was associated with minor bleeding from an angiomatous malformation and stopped when the Orgaran ® dose was reduced. However, of the 11 patients receiving >400 U/hour, four suffered major bleeding (three fatal) and two developed minor bleeding. Most of these patients received continuous arterio-venous haemodiafiltration treatment, which may have been a contributory factor. Conclusions We recommend that maintenance Orgaran ® infusion rates ≥400 U/hour should be avoided unless serious circuit clotting is grossly affecting the haemofilter life. The infusion rate should be monitored clinically; that is, on the basis of bleeding and circuit clotting rather than the patients' plasma anti-FXa responses. 

Introduction Heparin-induced thrombocytopenia (HIT) presents with thrombocytopenia and high risk for venous and/or arterial thrombosis, as an adverse effect of heparin (especially unfractioned). Objective To evaluate the incidence of positive heparin antibody test in a multidisciplinary ICU for the time period from 1 January 2006 to 30 November 2006. Methods We retrospectively reviewed all laboratory tests for heparin antibodies requested from the ICU for the period of January-November 2006. The blood sample analysis was performed with ELISA (Asserachrom ® HPIA; Diagnostica Stago, Asnieres, France). All patients were receiving fractioned heparin subcutaneously for prophylaxis when indicated. Flushes of unfractioned heparin for catheter clotting prevention were given to all patients. Only 'positive' results were considered positive, whilst 'mildly positive' and 'uncertain' results were considered negative. Results During that period 300 patients were admitted (mean duration of stay 15 ± 16 days, 25th-75th 4-22 days) to the ICU; 212 (70%) were survivors and 88 (30%) were nonsurvivors. All patients presenting with thrombocytopenia (platelets < 150,000/dl) or showing a decrease >50% of their admission day's platelet count were checked for heparin antibodies. Fifty-two samples retrieved from 48 patients suspicious for HIT were sent for heparin antibody analysis. Of the 48 patients checked, 15 (31%) were positive and 33 (68%) negative. Three of the suspected patients suffered from pulmonary embolism and were treated with therapeutic doses of i. v. unfractioned heparin; one of them was positive for heparin antibodies. Conclusions Our findings of high incidence of positive heparin antibodies may be mainly due to unfractioned heparin flushes. The use of heparin flushes with the new high-quality catheters and monitoring kit is questionable. Since low doses of unfractioned heparin could lead to the production of antibodies and subsequently to HIT, further studies should examine the risk-to-benefit ratio of the use of unfractioned heparin flushes in the ICU setting.
section_name: Results

section_content: The beneficial effects of the combined methods in investigating heparin-induced thrombocytopenia Introduction Heparin-induced thrombocytopenia (HIT) type II is a serious side effect of unfractionated heparin, and to a lesser extent of low molecular weight heparins. It is mediated through an immunological mechanism and leads to platelet aggregation. The occurrence of HIT varies between 1% and 5% of patients receiving heparin while a substantial fraction of them develops thrombosis (HITT). Therefore, the rapid and accurate confirmation of HIT is a necessity. The laboratory assays available for the diagnosis of HIT are based on the detection of HIT antibodies or on the consequences of platelet activation (functional methods). 

The purpose of the present study was to improve HIT recognition by the combination of functional and antibody determination assays. 

Patients and methods Fifty-three patients who presented thrombocytopenia while receiving UFH or LMWH participated in the study. A positive control group consisting of 15 patients known to suffer from HIT/HITT was used. Moreover, 19 healthy donors never exposed to heparin also participated as negative controls. 

The antibody determination was performed using commercially available ELISA kits. In the functional assays, heparin-induced platelet activation/aggregation (HIPA) and a flow cytometric technique for the detection of platelet microparticles released (platelet microparticle assay) were included. 

Results None of the negative control individuals were positive in any applied method. In contrast, all the participants of the positive control group were found positive in all the applied methods. No HIT was detected in 10 patients, seven of whom were pregnant at different gestational ages. The remaining 43 thrombocytopenic patients were positive in HIPA and 39 of them were also positive in the platelet microparticle assay. Out of these 39 patients, only 16 were positive in the ELISA assay. Conclusions In comparison with the HIT-positive control group it was found that: a 92% agreement existed between the HIPA and the platelet microparticle assays; and the positive results in the ELISA were significantly lower than in the functional methods, indicating perhaps a lower sensitivity (41% agreement with the flow cytometric method and 32% with the HIPA). Therefore, the combination of functional and antibody detection assays is a necessity for the HIT recognition since both could give pseudopositive or pseudo-negative results.
section_name: P373

section_content: The effect of male-donor-only fresh frozen plasma on the incidence of acute lung injury following ruptured abdominal aortic aneurysm repair Secondary outcomes were time to extubation, and survival at 30 days. Chest X-rays were examined independently by two radiologists who were blinded to the study hypothesis. 

Results One hundred and twenty-nine patients were operated on before and 82 after the change in FFP procurement. Groups were well matched, with respect to age, sex, co-morbidities and severity of illness, and received similar volumes of i. v. fluids and blood products from admission to 6 hours postoperatively (mean units of FFP, 8. 6 before and 8. 39 after, P = 0. 833). The maximum tidal volume, PEEP, and CVP were similar in both groups. 

Norepinephrine was given to 8. 5% of patients in the before group compared with 24. 4% after (P = 0. 001), otherwise inotrope use was similar. Primary outcome: there was significantly less ALI following the change to male-only FFP (36% before vs 21% after, P = 0. 042). Secondary outcomes were not statistically different between groups; however, patients with ALI in either group had a poorer 30-day survival (59% vs 80%, P = 0. 005). Conclusion Exclusion of female-donor FFP was associated with a statistically significant reduction in the incidence of ALI in patients undergoing repair of a ruptured AAA.
section_name: P374

section_content: A Heger, J Römisch, T Svae Octapharma PPGmbH, Vienna, Austria Critical Care 2007, 11(Suppl 2):P375 (doi: 10. 1186/cc5535)
section_name: P375 A biochemical comparison of Octaplas with a universally applicable development product (Uniplas) and singledonor fresh-frozen plasmas subjected to methylene-blue dye and white-light treatment

section_content: The aim of this study was to perform an extensive biochemical comparison of the pharmaceutically licensed coagulation active plasma Octaplas with an identical, but universally applicable, development product (Uniplas) and singledonor fresh-frozen plasma (FFP) units subjected to a medical device treatment using a combination of methylene-blue dye and subsequent white-light exposure (MB plasma). 

Methods Twenty-four batches of Octaplas of different blood groups and different plasma sources, three batches of Uniplas (both products manufactured by Octapharma PPGmbH, Vienna, Austria) and 20 random commercially available bags of MB plasma of different blood groups were analysed. Beyond the global coagulation parameters, the activities of coagulation factors and protease inhibitors, as well as plasminogen, activated factor VII, plasma turbidity and lipid components, were quantified. Results Similar to Octaplas, Uniplas showed standardised levels of coagulation factors, plasminogen and protease inhibitors (decreased protein S and antiplasmin activities) according to the product specifications. MB plasma revealed fibrinogen levels close to or below the physiological range (<1. 5 mg/ml). Coagulation factor activities in single MB plasma units both below and above the normal ranges for FFP were found in this study, reflecting the considerable variability of clinically important plasma proteins. Moreover, MB plasma revealed a higher turbidity after thawing, probably due to the elevated lipid parameters.
section_name: Introduction

section_content: This study showed that there are significant differences in the biochemical characteristics between Octaplas and MB plasma, while Uniplas revealed the same high quality as Octaplas. 

The variability of several plasma proteins in the 20 individual MB plasma units tested was high compared with Octaplas/Uniplas. For plasma prescribers and physicians it is also important to consider the significant loss of functional fibrinogen in MB plasma when planning and monitoring the treatment of severely ill patients.
section_name: Conclusion

section_content: T Franken 1, W Rees 2, N Hübner 2, J Albers
section_name: P376 Octaplex in routine clinical use for prophylaxis and therapy of bleeding in patients with prothrombin complex factor deficiency

section_content: The median total dose was 41. 1 IU/kg body weight (range 15. 3-83. 3 IU/kg body weight). In total the mean infusion rate was 6. 42 ml/minute for the first infusion. In about one-third of the patients an average infusion rate of ≥8 ml/minute was used. The median INR decreased from 2. 8 (1. 5-9. 5) to 1. 1 (1. 0-1. 9) after 10 minutes and remained at that level at measurements 30 and 60 minutes after infusion. There was a rapid increase in coagulation factor activity within the first 10 minutes as well. This activity remained stably elevated for at least We used questionnaires for indications and effectiveness of treatment. We compared the amount of blood lost within 12 hours before and within 12 hours after giving rFVIIa, the dynamics of bleeding (assessed in ml/hour) before and after treatment. We also compared the haemoglobin level, haematocrit, number of platelets and laboratory coagulation profile parameters before treatment, 2 hours and 12 hours after treatment. NovoSeven was administered 5-49 minutes after neutralization of heparin with protamin sulfate. The dosage of rFVIIa was 39. 23 ± 20. 70 µg/kg (range 14. 45-81. 35). We used Student's t test for statistical analysis the laboratory data prior to and after rFVIIa. 

Results Indications for administration of the rFVIIa were considered when there was a postsurgical bleeding (exceeding 400 ml/hour) in the absence of surgical sources of the bleeding and lack of efficacy of the conventional hemostatic procedures. 

After administration of the first median dose (14. 45-81. 35 µg/kg) rFVIIa bleeding stopped in 11 patients. A marked decrease occurred in seven patients during 2 hours. The average blood lost within 12 hours before treatment was 2,510 ml and the average blood lost within 12 hours after treatment was 1,057 ml. The average dynamic of bleeding before treatment was 1,057 ml/hour and 87. 90 ml/hour after treatment. The reduction in transfusion requirements was statistically significant. Conclusions NovoSeven produces a potent haemostatic effect in bleeding events refractory to the conventional therapy complicating the cardiosurgical interventions, and substantially decreases the demand for blood transfusion.
section_name: Results

section_content: Evaluation of the role of recombinant activated factor VII (NovoSeven) as a rescue haemostatic therapy in postcardiopulmonary bypass surgical patients Z Chen 1, V Rasiah 1, A Dewhurst Objective Evaluation of the safety and efficacy of recombinant activated factor VII (NovoSeven) when used as a rescue haemostatic agent in refractory bleeding post bypass surgery. Methods A retrospective cohort study of all postcardiopulmonary bypass patients with uncontrolled bleeding despite conventional treatment (platelets, fresh frozen plasma, cryoprecipitate, and Aprotonin) who received recombinant factor VII as a rescue therapy over 12 months in a cardiothoracic centre. 

Results Eight patients received NovoSeven (90 µg/kg). Seven achieved significant reduction in blood loss. The mean blood loss via thoracic drains 6 hours before and 2 hours after NovoSeven administration were 341 ml/hour vs 117 ml/hour (P = 0. 01) (Figure 1 ). On average, 5. 3 units/patient packed red blood cells, 2 pools/ patient platelets, 19 ml/kg/patient fresh frozen plasma and 148 ml/ patient cryoprecipitate were used prior to NovoSeven administration. Five patients required further blood transfusion with a mean of 2. 2 units/patient over the next 12 hours. Two of the eight patients developed thromboembolic complications including portal vein thrombosis and spinal cord infarction. Of these two, one died secondary to coagulopathic complications post initiation of warfarin therapy 2 weeks post surgery.
section_name: P379

section_content: Our results support the evidence that recombinant factor VII is an effective haemostatic agent that can be used in patients with uncontrolled bleeding in postcardiopulmonary bypass surgery. Despite its high cost, there is an advantage in terms of effectiveness to support its use. However, its potential thromboembolic risk remains a concern and current evidence may restrict its use only as a rescue therapy following failed conventional treatment.
section_name: Conclusion

section_content: Factor VII for intractable bleeding after cardiac surgery Patients receiving RF7a between January 2004 and September 2005 were identified via pharmacy records. Clinical databases and electronic medical records were reviewed, collecting data elements needed to assess study objectives. One hundred and twenty patients were identified. Twenty-seven patients were excluded because they lacked documentation of RF7a administration, were treated for neurologic indications or had incomplete medical record data. Ninety-three patients were analyzed. RF7a effectively achieves hemostasis in patients with intractable bleeding, reducing blood product transfusions within 6 hours of treatment (Figure 1 ). Our findings suggest differences in PRBC transfusion reduction between RF7a doses. We observed no additional reduction PRBC transfusions in patients administered doses greater than 60-90 µg/kg (Figure 2 ). Effects of RF7a on surgical re-exploration and other potential related adverse events (stroke, AMI, VTE, etc. ) are forthcoming. Our study, like others evaluating RF7a for this indication, are limited by the retrospective scope. Randomized trials comparing RF7a doses are under way. Although RF7a therapy is costly, minimal reductions in surgical reexploration may offset the cost of RF7a therapy provided that adverse events are not increased.
section_name: P380

section_content: The influence of severe preeclampsia on maternal cerebral perfusion Results All haemodynamic values in preeclamptic patients were decreased in comparison with the same values in healthy pregnant women: PI (mean 0. 71 vs 0. 84, P < 0. 0001); RI (mean 0. 49 vs 0. 54, P < 0. 0001); V ps (mean 72. 8 vs 104. 8 cm/s, P < 0. 0001); V ed (mean 34. 7 vs 48. 7 cm/s, P < 0. 0001); TAMX (mean 48. 5 vs 67. 5 cm/s, P < 0. 0001); S/D (mean 1. 94 vs 2. 05, P < 0. 001). These pathophysiological changes of cerebral haemodynamics were consistent with the Dopplerographic pattern of diminished perfusion and are typical for vascular segments, which are located proximally to the zone of abnormally high haemodynamic resistance.
section_name: P382

section_content: The results of the performed study showed that patients with severe preeclampsia had decreased cerebral perfusion and TCDS is an effective method for estimation of preeclampsia severity. low platelet count. Maternal mortality was reported to be as high as 24%. Two classifications of the HELLP syndrome are widely used (Tennessee [1] and Mississippi [2] ). The aim of this study is to determine mortality of HELLP syndrome as defined by each classification and try assessing the most relevant. 

Patients and methods Prospective data collection as part of the APRiMO study (Assessment of Prognosis and Risk of Mortality in Obstetrics). Included were all obstetric patients transferred from a referral center for high-risk pregnancies in our independent multidisciplinary ICU. The study period was January 1996-September 2004. Demographic data, obstetric history, morbid events, length of stay (LOS), severity of illness scoring systems and organ dysfunction scores at day 1 of admission were collected. Exclusion criteria were LOS < 4 hours. The main outcome of interest was survival status at ICU discharge. Two groups were compared: patients with HELLP syndrome as defined alternatively by the two classifications (Group I), and patients without hepatic dysfunction (Group II). Results are expressed as the mean ± standard deviation. P < 0. 05 was considered significant. Discrimination of the classifications was assessed by the area under the receiver operator characteristic curve (AuROC). Calibration was assessed by the Hosmer-Lemeshow (HL) goodness-of-fit test. Data were computed on SPSS 11. 5, Win-XP compatible. 

Results and discussion Differences between Group I and Group II were statistically significant concerning obstetric hemorrhagic complication (P < 0. 001), incidence of acute renal failure (P = 0. 01), mortality (P = 0. 001), LOS (6. 5 ± 7 days vs 4. 4 ± 4 days, P = 0. 001), SAPS-Obst score (24. 5 ± 8 vs 16. 8 ± 7, P < 0. 001). 

The Mississippi classification discriminated well, but calibrated badly. In contrary, the Tennessee classification was a poor discriminator but calibrated very well. See Table 1. The majority of events (45 patients, 83%) occurred in the third trimester and postpartum period (P = 0. 02). A specific cause was identified in 24 patients (80%) of IS and in 21 patients (87%) of HS. Causes of IS include preeclampsia/eclampsia in 11 patients, venous thrombosis and coagulopathies (deficiencies of protein C, protein S, and activated protein C resistance) in nine patients, valvular heart disease with history of prior stroke in four patients and six patients had no definable cause. The major causes of HS were preeclampsia/eclampsia in eight patients, four patients presented with hemorrhage secondary to aneurysmal rupture, three patients presented with bleeding from arterio-venous malformations (AVM), bleeding as a consequence of disseminated intravascular coagulation (DIC) occurred in two patients and seven patients had hemorrhagic events of unknown origin. Hypertensive disorders of pregnancy were the most common comorbid conditions (32%). Nineteen deaths (35%) occurred in our study, eight patients with infarction and 11 patients with hemorrhage. Thirty-one patients left the hospital with neurologic deficits, requiring chronic care or rehabilitation.
section_name: Conclusion

section_content: The results of the present study complement the findings of previous studies on timing of stroke in pregnancy [1, 2]. We found that preeclampsia/eclampsia and intracranial vascular malformations were the major causes of stroke in pregnancy, which agrees with other findings [2, 3]. Our study shows a high mortality rate of 35%, which indicates that careful management of at-risk patients during the first postpartum weeks is warranted. 

Introduction Acute renal failure (ARF) was newly recognized as a specific mortality risk factor [1] and is in general associated with a high mortality rate. The aim of this study was to evaluate FEU in the follow-up of ARF due to prerenal azotemia in order to predict the necessity of renal replacement therapy (RRT). The prospective study took place at the ICU of Stadtspital Waid, Zürich. All patients admitted starting from 19 February 2006 were evaluated for ARF according to the RIFLE classification. ARF due to prerenal azotemia was defined as ARF combined with FEU of less than or equal to 35%. FEU was calculated as [(urine urea/blood urea)/(urine creatinine/plasma creatinine)] x 100. Urine specimens were taken and FEU was calculated daily until complete or partial renal recovery was reached or the criteria for RRT were met. The goal of therapy was reconstitution of renal function by treatment of the underlying condition. RRT was initiated according to the usual criteria. Statistics were determined using Fisher's exact test.
section_name: Discussion and conclusion

section_content: Available online http://ccforum. com/supplements/11/S2
section_name: Hypothesis

section_content: Fractional excretion of urea (FEU) in the follow-up of acute renal failure (ARF) due to prerenal azotemia. Data presented as mean ± SD. n = number of patients. 

By 7 December 2006, 15 patients met the inclusion criteria for ARF due to prerenal azotemia (nine males, six females). The mean age was 71 ± 11 (SD) years for male patients and 58 ± 31 years for female patients. Twelve out of the 15 patients responded to conservative management and had complete or partial renal recovery. Three patients needed RRT. Two of them refused RRT and died during the course of the disease. During the first 48 hours after initiation of conservative therapy, FEU remains less than or equal to 35% in all three patients who needed RRT. By contrast, nine out of 12 patients in whom renal function recovered without RRT showed a FEU of more than 35% within the first 48 hours (P < 0. 05) (Figure 1 ). In patients presenting with ARF due to prerenal azotemia, an increase of FEU above 35% within the first 48 hours after initiation of conservative therapy for ARF is a valuable parameter to predict renal recovery. After initiation of conservative therapy, measurement of FEU is of no value concerning discrimination of prerenal azotemia and acute tubular necrosis in ARF.
section_name: Figure 1 (abstract P387)

section_content: Hemodynamic goal-directed intermittent hemodialysis ). There were significant differences between median Gc globulin in ALF patients compared with ACLD: 25 mg/l (10-50) vs 50 mg/l (25-129), P = 0. 036. No significant differences were seen for NGAL. Gc globulin correlated with admission creatinine (r = 0. 44, P < 0. 01), INR (r = 0. 68, P < 0. 01), and SOFA score (r = 0. 419, P < 0. 01) in both patient groups. These relationships persisted when admission Gc globulin was examined in regard to day 5 parameters. Admission Gc globulin correlated with D3 urine output (r = 0. 619, P < 0. 001). NGAL correlated with urine output throughout the first 5 days of admission (r = -0. 593 on day 1, r = -0. 674 on day 3, P < 0. 001) and also with SOFA score. High admission NGAL was associated with requirement for renal replacement therapy on day 3 (ROC AUC 0. 91 (0. 895-1. 022, P < 0. 001)), outperforming both admission Gc globulin and admission creatinine. A low admission Gc globulin more accurately predicted the need for haemofiltration on day 5 (AUC 0. 889, 0. 734-1. 044, P < 0. 007) than either NGAL or creatinine on admission. There were significant differences observed for Gc globulin examining 30-day survival (transplantation from ITU being analysed as 'death'): 50 mg/l (29-94) vs 18 (4-40), respectively, AUC 0. 813, P = 0. 006. There were no significant differences in NGAL values between survivors and nonsurvivors for the whole group. NGAL was significantly lower in survivors than nonsurvivors in the ACLD group (AUC 0. 875, P = 0. 47). Conclusion Gc globulin and NGAL are potentially useful methods of identifying patients with a particularly poor prognosis and those needing renal replacement therapy. Further larger prospective studies are needed to elucidate their exact role not only in liver disease but also in the general ITU population.
section_name: P388

section_content: Fibrinogen as a prognostic indicator in hepatic failure
section_name: P395

section_content: The two groups of 38 patients were comparable in age (52. 4 and 56. 5 years), ASA physical status (1. 9 and 2. 0), preoperative albumin concentration (39. 0 and 38. 1 g/l), duration of operation (5. 9 and 6. 1 hours), transfused red blood cells (3. 3 and 2. 0 l) and crystalloid infusion during surgery (5. 3 and 4. 5 l). In both groups there was very significant drop of albumin concentration in the first week after surgery (P < 0. 001). In group 2 albumin concentrations were very significantly lower than in group 1 until the fifth postoperative day (P < 0. 001). The difference diminished after the sixth postoperative day (P < 0. 03). There was negative correlation between the postoperative albumin concentration and the duration of surgery (r = -0. 44, P < 0. 008). We found no difference in the postoperative complication rate (surgical or medical), length of stay and mortality between the groups. The aim of this study was to compare the effect of hydroxyethylstarch (HES) and human albumin solution (HAS) on human neutrophil elastase (HNE) release in patients undergoing elective knee replacement surgery. Forty-three patients (ASA 1 or 2) were randomly allocated into two groups. Group A (n = 21) received 5 ml/kg of 4. 5% HAS preoperatively and a further 5 ml/kg HAS as an intraoperative replacement. Postoperatively the patients received Ringers' lactate at the discretion of the anaesthetic team. Group B was given 5 ml/kg HES (Fresenius-Kabi) preoperatively and a further 5 ml/kg HES intra-operatively. Thereafter fluid management was as in group A. Arterial blood samples were taken preoperatively and at 5 minutes, 30 minutes, 60 minutes, 120 minutes, 240 minutes and 24 hours post-tourniquet release for HNE and arterial blood gas analysis. Repeated measures of analysis of variance established a significant difference in the pattern of change of HNE levels (log transformed) and the PaO 2 /FiO 2 ratios with time between the two groups. Follow-up t tests revealed significantly lower levels of HNE (Table 1 ) and also significantly higher PaO 2 /FiO 2 ratios in Group B post-tourniquet release. 

In conclusion, the results suggest that infusion of HES lowers HNE release from activated neutrophils in postoperative knee replacement patients and may lead to less lung injury.
section_name: Results

section_content: M Cury-Boaventura This relationship is, in part, due to the red cell chloride shift. However, according to the Stewart quantitative approach to acidbase balance, it seems conceivable to expect a greater relationship between the strong ion difference (SID) and bicarbonate, rather then between chloride and bicarbonate. We propose that, with decreasing haemoglobin (Hb) levels, the SID preserves its independent role with respect to bicarbonate, while chloride gradually loses its relationship. Methods We retrospectively collected blood gas analysis and electrolytes, from 206 patients, measured on a single blood sample taken on admission. We calculated the apparent SID through the following formula:

(mEq/l). We divided patients into three groups based on Hb levels: group A (n = 54) with Hb levels between 12 and 15 g/dl, group B (n = 104) with Hb levels between 9 and 12 g/dl, and group C (n = 48) with Hb levels below 9 g/dl. We calculated Pearson's coefficients between the SID and bicarbonate and between chloride and bicarbonate in these three groups of patients. 

Results Correlation strength between the SID and HCO 3 -was high and significant even at a Hb concentration below 9 g/dl (see Table 1 ). Pearson's coefficients for chloride and bicarbonate showed a moderate but significant inverse correlation in group A and group B; eventually this correlation was completely lost in group C. There was a significant difference between preT and postT SvcO 2 (70. 9 ± 8. 66 and 73. 6 ± 7. 2, P = 0. 01) but not in LAC levels (24. 1 ± 8. 9 and 22. 9 ± 7. 6, P = 0. 45). When groups were analyzed separately, only in Group 2 was a significant difference found (P = 0. 0005 and 0. 05, respectively for SvcO 2 and LAC). In 10 transfusions a worsening of SvcO 2 postT was observed and all these patients had preT SvcO 2 > 70%. Although there was no significant correlation between a worsening in SvcO 2 and preT Hb, eight of these patients were allocated to Group 1. Another 13 transfusions were done with a SvcO 2 preT < 70, and 10 of them improved (> 5%) after transfusion (mean percentage of improvement = 18. 9%). Only four of these patients were allocated to Group 1. Patients with high levels of preT LAC (n = 21) only improved (reduction > 10%) in 42. 9% of cases. A total 53. 3% of patients with normal preT LAC levels worsened (rising > 10%) postT. The mean preT Hb from these patients was 8. 18 ± 0. 9. There was a significant difference between the pretransfusion Hb (P < 0. 00001) and the number of RBC transfused at the same time considering all ICU enrolled in the study (P < 0. 00001).
section_name: P408 Toxicity of two lipid emulsions on human lymphocytes and neutrophils

section_content: The Hb level that triggered transfusion was in agreement with recent guidelines regarding critically ill patients, although there was a difference between all ICUs. Despite the fact that there is a scarceness of RBC, the RBC were higher in age. 

The missing correlation with mortality can be due to the small sample size.
section_name: Conclusions

section_content: The awakening of the residual risks of blood transfusion leads, everywhere in the world, to efforts to reduce them. The aim of the study was to assess the transfusion practices in Tunisia. Discussion and conclusion The evolution of the blood transfusion was remarkable, since the use of total blood in the 1980s, with the acquisition of the first techniques of separation of the blood components. The transfusion practice in Tunisia is far from being to the standards. The results obtained make it possible to transmit to the clinician the failures of the system, to better include how to prescribe a blood product, to follow its effectiveness and its possible side effects, and to apprehend the impact of the innovated biotechnologies to improve quality of transfusion medicine in coherence with the security requirements. Results Twenty-nine (82. 9%) out of a total of 35 possible hospitals answered, including 113 (57. 7%) answers out of a total of 196 possible answers. Ninety-seven per cent of the physicians were specialists in anaesthesiology. Eighty-seven per cent of the nurses were certified intensive care nurses. Forty-seven per cent were from university hospitals. Twenty-six per cent had a sedation protocol, 37% of the physicians and 14% of the nurses. Only one-third of the ICUs had a protocol for sedation. Sixty-eight per cent having a protocol used it always or often, whereas 32% never use it. Sixtyseven per cent had a sedation scoring system in their departments. The scoring systems used was: Ramsay 49%, Sedation Agitation Score 10% and own (locally made) scoring system 41%. Twentytwo per cent answered that the scoring systems was always used, 58% often and in 20% the scoring systems was seldom used. Forty per sent use the 'wake-up call' test, 63% physicians and 37% nurses. Sixty per cent answered 'no we do not use' the wake-up call test, 47% physicians and 53% nurses. Withdrawal symptoms were experienced more than three times as frequently by nurses compared with physicians (31% vs 9%). Five times as many experienced withdrawal symptoms in the group not having a sedation and analgesia protocol (84% vs 16%). Conclusions There is still a great educational potential for improving the use of sedation protocols and implementing sedation scoring systems and the wake up test in Danish ICUs. This potential could perhaps reduce the incidence of withdrawal symptoms. Effort should also be placed in implementing the sedation protocol in the ICU, illustrated by the differences in numbers of doctors and nurses having a sedation protocol.
section_name: Introduction

section_name: P414

section_content: M Moustafa 1, M Borai Introduction Inhalational ICU sedation is increasingly applied since the introduction of AnaConDa ® (Sedana Medical, Sweden). This anaesthetic-conserving device (ACD) retains exhaled sevofluorane (SEV) and resupplies it during inspiration [1]. A syringe pump delivers liquid SEV into the device. Since January 2004 we have used the ACD as a standard practice. Our patients anaesthetised with SEV in the OR and scheduled for ICU sedation with SEV only need propofol on transport. Could this be avoided when using the ACD during transport? Methods Forty-one patients after major abdominal surgery were included in this quality assurance project. In 20 patients the ACD was inserted into the anaesthesia circuit to take up warmth, humidity and SEV for 15 minutes and used for transport. SEV infusion was started in the ICU after gas monitoring. Twenty-one patients scheduled for propofol sedation served as controls. 

During transport all patients were ventilated with Oxylog2000 (Dräger, Germany), vital parameters were monitored, and the Ramsay Score (RS) was assessed at five time points. If necessary, propofol injections of 0. 5 mg/kg were given. Methods In a prospective study, pain location, distribution (number of pain areas per patient), and intensity (0-10 numerical rating scale) were documented on 250 consecutive adult patients on the first, second and third postoperative day (POD). Patient characteristics (age, sex, size, and body mass index) were analyzed for their impact on pain intensity. There were 140 male and 110 female patients, with a mean ± SD age of 65. 7 ± 13. 5 years.
section_name: P422 Evaluation of two sedation techniques in a casualty department

section_content: The maximal pain intensity was significantly higher on POD 1 and 2 (3. 7 ± 2 and 3. 9 ± 1. 9, respectively) and lower on POD 3 (3. 2 ± 1. 5). The order of overall pain scores among activities (P < 0. 001) from highest to lowest was coughing, moving or turning in bed, getting up, deep breathing or using the incentive spirometer, and resting. After chest tubes were discontinued, patients had lower pain levels at rest (P = 0. 01), with coughing (P = 0. 05). Age and sex was found to have an impact on pain intensity, with patients <60 years old and male patients having a higher pain intensity than older patients on POD 2 (4. 7 ± 2. 0 vs 3. 2 ± 2. 4, P = 0. 02 and 4. 5 ± 2. 3 vs 2. 9 ± 2. 2, respectively). Conclusions Pain relief is an important outcome of care. A comprehensive, individualized assessment of pain that incorporates activity levels is necessary to promote satisfactory management of pain. We recommend the use of remifentanil infusion for postoperative pain relief in suitable cardiac surgery patients.
section_name: Results

section_content: A Schmidt 1, I Welters Methods After approval of the local ethics committee and written informed consent, 315 patients scheduled for elective 'on-pump' CABGS were enrolled in the study. Patients were randomly allocated to three anesthetic protocols: sufentanil-sevofluoranepropofol (SSP), sufentanil-propofol (SP), and S-(+)-ketaminemidazolam-propofol (KMP). Standard invasive hemodynamic monitoring was performed using a pulmonary artery catheter and hemodynamic variables were reported. Measurements were taken after induction of anesthesia, after weaning from cardiopulmonary bypass, and 6 hours postoperatively. Serial plasma troponin T levels were taken: before induction of anesthesia, after surgery, and 6 and 24 hours postoperatively. All cardiovascular adverse events were recorded (such as electrocardiographic signs of ischemia, myocardial infarction, 28-day mortality). 

Results Groups (SSP: n = 106; SP: n = 108, KMP: n = 101) did not differ in preoperative data (for example, biometry, cardiac and coronary profile and risk). Intraoperative management was comparable among groups. Tropinin T levels were rather lower in the KMP group, but did not differ significantly between groups at 24 hours after aortic unclamping. Cardiovascular adverse events showed the same low incidence in all groups. Hemodynamic data were comparable; however, the heart rate (HR) and mean arterial pressure (MAP) after induction were significantly higher in the KMP group (HR: 59 ± 11 vs 63 ± 32 vs 66 ± 13 beats/min (P < 0. 01); MAP: 74 ± 12 vs 81 ± 16 vs 83 ± 16 mmHg (P < 0. 01)).
section_name: P430 Opioid receptor expression on neutrophils: effect of tumour necrosis factor alpha treatment

section_content: In our study, KMP anesthesia was safe to use for CABGS. In comparison with SSP and SP anesthesia, no significant rise in troponin T as a marker of myocardial damage was observed. All three regimens resulted in stable hemodynamics. However, the use of S-(+)-ketamine as an induction agent in patients with coronary artery disease may be limited due to its sympathomimetic effects leading to raised HR and MAP, even if supplemented by midazolam or propofol.
section_name: Conclusion

section_content: Computer management systems and protocols in intensive care units: do we have any benefit? The objective of this study was to systematically review the literature on CMS/P to evaluate their impact on outcome benefit. Methods A Medline search from 1996 to 2006 with the following key words was performed: critical care or intensive care, and protocol, and data management system or computer management system or computerized documentation.
section_name: P432

section_content: The search revealed 21 potential articles. The language was English in 18 of the articles, two in German and one in Japanese. Of those 21, 10 articles were not studying CMS/P. Of those 11 that fulfilled the criteria, computer management systems were studied in four articles and treatment protocols in 11 articles. The combination of ICU treatment protocol and computer management system was studied in four of the 21 articles. Of those 11, three of the studies demonstrated that the implementation of a protocol to computer management system increases staff compliance to the protocol. The newer studies showed also that the costs were not increased by the computerised protocol. However, no definite benefit in patient survival or ICU length of stay could be demonstrated (11 of 21 studies). The combined absolute reduction rate in hospital mortality was 2% (95% CI 0-4%) in those four (19% of 21) studies. CMS/P increased the ICU length of stay 3. 5 days (95% CI 1. 6-5. 4 days) and decreased the hospital length of stay 5. 9 days (95% CI 1. 0-10. 8 days), in two different studies. Conclusion Our results could not confirm any definite benefit from computerised data management systems or treatment protocols regarding outcome. The ICU personnel adherence to treatment protocols seems to increase when implemented into the computerised data management systems. Further research on this topic is needed to justify the investments in computer management systems.
section_name: Results

section_content: Decreasing the incidence of ventilator-associated pneumonia using the FAST-HUG evaluation This abstract outlines the use of simulated critical care telephone calls into the education of trainees. We hope others may consider it for their centres. The Capital Health Region provides advanced healthcare for 2 million people, but spread over 9,800 km. We therefore rely heavily on transportation of critically ill patients to a single urban centre. In addition to geographic and climatic factors, bed pressures complicate how we triage, stabilize, transport and receive those patients. A major strategy is the 'Critical-Care-Line': a 24-hour telephone service with teleconference capabilities and contact numbers. However, experience suggests it takes practice to become proficient with its use. Given the importance of optimal communication, we arrange simulated calls. Senior trainees are paged during a normal workday by the Critical-Care-Line: just as they will be once in independent practice. The facilitator then assumes the role of a referring doctor in a small town. Peer-reviewed cases are used that include pertinent teaching points. Introduction As a result of centralisation of PICU services in the United Kingdom, transfer of critically ill children has become common over the past decade. It is not uncommon to receive multiple retrieval requests simultaneously, thus a tool to prioritise the urgency of this would be beneficial. Our aim was to develop such a tool and assess its inter-rater repeatability. Methods The tool was developed by three senior medical staff of the South Thames Retrieval Service (operating from the PICU at Evelina Children's Hospital, London with 1,000 calls per annum from 24 district general hospitals, resulting in 600 retrievals). A modified Delphi method was used, which comprised an iterative process including a literature review, knowledge of the underlying conditions and a review of retrievals performed by the service over the previous 7 years (n = 3,669). Inter-rater agreement was assessed using the weighted kappa statistic, and was measured between various pairings of junior and senior medical staff (n = 28 combinations) on 50 retrieval episodes.
section_name: P433

section_content: The final tool comprised five categories (three levels of severity each) allowing for a range of scores from 0 to 15 (Figure 1 ). Three levels of urgency were defined: semi-urgent (score <8), urgent (score 8-10), immediate (score >10). Overall the tool showed a good to very good strength of inter-rater agreement (kappa scores ranging from 0. 65 to 0. 88; Figure 2 ). There were no obvious differences between levels of staff seniority.
section_name: Results

section_content: The score showed acceptable agreement, fullfilling the first step of validation. There was also a significant increase in the incidence of sub-30-minute mobilisation times, which almost doubled after 2004 with the availability of an onsite dedicated ambulance service (14. 3% to 25. 9%, P < 0. 0001). Conclusion There has been a significant decrease in the mobilisation time of the STRS over the last 5 years. Although the presence of an onsite ambulance service in 2004 had a significant impact on reducing retrieval mobilisation times, a number of other factors and initiatives contributed to steadily reducing mobilisation times over the study period.
section_name: Conclusion

section_name: P441

section_content: Ambulance transport is associated with a higher mortality than private transport following major penetrating trauma in a semi-urban environment Aims The use of private transportation has been associated with improved outcomes in urban trauma patients. The need for patient stabilization at the scene needs to be balanced with the need for early operative intervention, and therefore the need for rapid transportation to hospital. Our aim was to assess the relationship between the mode of transport to hospital and outcome in a semiurban trauma environment. Methods Data were collected prospectively on 1,396 patients admitted to a Level 1 South African trauma unit over a 1-year period. The Revised Trauma Score was used to assess injury severity and physiological derangement at the time of admission, and to allow comparison between the groups. Mortality was defined as death within 30 days.
section_name: P442

section_content: The mortality in the blunt trauma patients (n = 527) was higher in the ambulance transport group, but this was not statistically significant. However, the mortality in the penetrating trauma patients (n = 808) was significantly higher in the ambulance transport group (P = 0. 020, chi-square; Table 1 ) despite similar Revised Trauma Scores (Table 1 ).
section_name: Results

section_content: The use of ambulance transportation is associated with a 3. 7-fold increase in mortality following penetrating injury. This may be related to longer times in the field resulting in delay to definitive care in hospital.
section_name: Conclusion

section_content: The Results Twenty-seven patients died. Patients carrying an A allele at position -863 produced more TNFα mRNA on day 1 than C homozygotes (P = 0. 037). There was a trend for patients homozygous for the G allele at position -308 to produce more TNFα mRNA on day 1 than those carrying an A allele (P = 0. 059). Carrier status for haplotype 1 (with A at position -863 and G at position -308) was associated with greater TNFα mRNA levels on day 1 (P = 0. 0374). Carrier status for haplotype 4 (with C at position -863 and A at position -308) was associated with a nonsignificant decrease in TNFα mRNA levels on day 1 (P = 0. 059). When directly compared, haplotype 1 was associated with significantly greater levels of TNFα mRNA than with haplotype 4 on day 1 (P = 0. 02). Patients homozygous for the A allele at position -308 were more likely to succumb to severe sepsis than those carrying the G allele (P = 0. 01).
section_name: P443

section_content: These results contradict previous in vitro functional studies on the TNF2 allele. This may be secondary to the method of quantification of in vivo gene expression with QRT-PCR providing more accurate and sensitive data when compared with prior ELISA-based assays. Indeed, the extrapolation of functionality from in vitro functional genetic tests after lipopolysaccharide stimulation may be of questionable value. We conclude that genotypic analysis does have a place in risk stratification in sepsis and that genetic variants at positions -863 and -308, or sites in linkage disequilibrium with these variants, may influence TNFα production.
section_name: Conclusion

section_name: P449

section_content: In critically ill patients with severe sepsis/septic shock a score based on age and increased plasma levels of cardiac biomarkers can help risk-stratify patients and predict short-term (<6 months) outcome.
section_name: Conclusion

section_content: The calculated ion gap: a novel predictor of mortality in the critically ill surgical patient We evaluated these anions as a novel marker of outcome. Methods We prospectively evaluated 109 consecutive patients admitted to a surgical high-dependency unit (HDU). Regional Ethics Committee approval was obtained. Serum electrolytes, albumin, phosphate and lactate were measured on admission and days 1 and 2. We derived the calculated ion gap (CIG) using our simplified modification of the Stewart-Figge equations.
section_name: P451

section_content: The CIG on day 1 predicted mortality (P = 0. 001, analysis of variance). A CIG > 10 mmol/l correlated very strongly with mortality. The mortality in patients with a CIG < 10 mmol/l (n = 86) was 4. 7%. The mortality in patients with a CIG > 10 mmol/l (n = 23) was 26. 1% (P = 0. 006, chi-square test). There were no differences in CIG with respect to mortality on admission or day 2 (P = 0. 273 and 0. 104, respectively). The mean hospital stay was significantly longer in patients with a CIG > 10 mmol/l (46. 6 vs 18. 7 days, P = 0. 015, t test) (Table 1 ).
section_name: Results

section_content: Results Eight patients (median age 68 years; six males/two females; SOFA score = 12) were enrolled in our study. The initial BNP level median increased from 695 (417-2,738) to 715 (478-2,596) µg/ml after a fluid loading (P = 0. 7) (Figure 1 ). We did not find a statistically significant relationship between BNP variation and left ventricule area variation after fluid challenge (P = 0. 13) (Figure 2 ). Conclusion There is no increase in BNP level in patients with septic shock after fluid challenge. To our knowledge, this preliminary study is the first to evaluate the relationship between BNP and left ventricule area variation in patient with septic shock. Although no statistical significance between left ventricule area variation and BNP variation after fluid challenge, there is a trend to correlation between these two parameters. More patients have to be included to confirm this result. the admission APII score (H1-APII) and H24-APII. The formulae to calculate individual mortality for H1 and H24 APII were those validated for H24-APII as stated by Knaus and colleagues [1], adjusting for admission diagnosis. We compared both scores by discrimination and calibration statistical tests. P < 0. 05 was the threshold for statistical significance.
section_name: S181

section_content: The study period was January 1996-September 2004. We included 541 patients, overall mortality was 10. 5%. Mean H1-APII and H24-APII scores. respectively. were 7. 6 ± 6. 1 and 8. 6 ± 7, with derived mean predicted mortality, respectively, of 8. 63% and 9. 86%. The H24-APII score was higher than the H1-APII score in 135 patients (25%), among those patients 32 died (24% of patients with worsened APII) vs 6. 16% if H1 = H24 (P < 0. 01). Running a multiple logistic regression with mortality as the dependent parameter, we found that worsening of the APII score over time is not significantly associated with mortality (P = 0. 791), whereas the H1-APII score (P < 0. 001) and ∆APII score (H24-APII The median maximum SOFA score was 5. 00 (IQR 5). The median length of ICU stay was 3. 0 days (IQR 3). The overall ICU mortality rate was 14. 0%. For patients with a maximum SOFA score ≤8, mortality was 5. 1% -vs 45. 5% for those whose maximum SOFA score was >8 (P < 0. 001). Sixty-four per cent of patients scored their maximum SOFA score on admission. In patients whose SOFA score increased after admission, the mortality was 24. 3%. Logistic regression analysis showed the maximum SOFA score bore a stronger correlation with mortality than admission SOFA score. See Results Nine out of 11 patients survived without any residual organ damage, and the remaining two died due to MODS (Figure 1 ). Both these patients had five organ dysfunctions on admission, and their SOFA scores were 18 and 20, respectively. They had a low parasitic index of 1% and 2. 5% and their PCT levels were 0. 5-2 and >10 (semiquantitative method), respectively. Their APACHE II scores were 16 and 10.
section_name: Results

section_content: The pretreatment APACHE II score, parasite index, PCT levels and number of organs involved have variable correlation with mortality and are not consistent predictors of outcome. A higher SOFA score on admission is a more reliable predictor of mortality in malarial MODS. We sought to describe Sequential Organ Failure Assessment (SOFA) score daily trends in septic patients and tried to correlate those trends with survival. Methods Patients with severe sepsis or septic shock admitted for at least 5 days in a seven-bed medicosurgical ICU of a Brazilian university hospital were studied. The daily SOFA score for each patient was calculated during the first 5 days of admission. Relevant data were prospectively acquired from March 2003 to May 2006 and the latter retrieved from a electronic database. ICU survivors were compared with nonsurvivors using the Mann-Whitney U test. Day-to-day changes were verified within each group using Friedman's test. P ≤ 0. 01 was elected as the significance limit. Medians and interquartile ranges (IQRs) were used to describe the sample. 

Results One hundred and seventy-six patients were studied (71 males (56%), median age 51 (IQR 36-67) years, 78 (44%) with severe sepsis, median length of ICU stay 10 days (IQR 7-16), median admission SOFA 6 (IQR 4-9), median APACHE II score 19 (IQR 13-26), ICU mortality 27. 84% (49/176 patients)). The SOFA score and its components scores along the five admission days distinguished the survivors from the nonsurvivors. Considering the SOFA score and its respiratory, neurologic and circulatory components, survivors presented lower scores as the days passed (P < 0. 001). Mortality was increasingly higher for those patients who persisted with a SOFA score ≥ 7 as the days passed.
section_name: Conclusion

section_content: In the sample studied, the persistence of an elevated SOFA score and its components during the first 5 days of admission predicted a higher mortality. Survival appears to be related to early organ dysfunction recovery. The SOFA score and SOFA-related variables' day-to-day changes in a population of septic patients may have an important prognostic implication and some patterns of daily evolution may distinguish those patients with a more ominous outcome.
section_name: Conclusion

section_content: Cumulative lactate load correlates with cumulative Sequential Organ Failure Assessment score and survival in intensive care unit patients P Spronk 1, L Brander 2, S Jansen 1, J Rommes
section_name: P466

section_content: The relationship between mortality and its time of day in intensive care unit patients Introduction Mortality of patients readmitted to the ICU is significantly higher than the mortality of patients treated once in the ICU. A simple method to predict mortality of patients readmitted to the ICU could help to select the most seriously ill readmitted patients. Methods Adult patients that were admitted to all three ICUs of the same hospital twice or more times during the same stay in the hospital during a 3-year period were retrospectively selected. The sex and age of surviving and nonsurviving readmitted patients were compared. The mortality rate of patients readmitted into the ICU during 24 and 48 hours was compared with the mortality rate of all readmitted ICU patients. The mortality of patients that were readmitted more than once into the ICU was compared with the mortality of patients that were readmitted once. The duration of stay in other departments before readmission into the ICU of survivors was compared with duration of stay in other departments of nonsurvivors. 

Results A total of 13,343 patients were admitted. Eight hundred and fifty-six patients were readmitted, 172 readmitted patients died in the hospital (hospital mortality -20. 09%). The readmission rate of men was higher in comparison with women (550 vs 306 patients). The mortality of readmitted men was lower than the mortality of readmitted woman; 77 men (17. 2%) died vs 95 (25. 1%) women (P = 0. 00001). The age of 565 patients was lower than 70 years. The mortality of readmitted patients with age lower than 70 years was lower than the mortality of patients older than 70 years; 103 (18. 2%) patients younger than 70 years died vs 70 (24%) patients older than 70 years (P = 0. 00001). Mortality of patients that were readmitted during 24 or 48 hours was bigger than the mortality of all readmitted patients (26. 9% and 25. 11% vs Critical Care March 2007 Vol 11 Suppl 2 27th International Symposium on Intensive Care and Emergency Medicine S187 20. 09%; P = 0. 045 and P = 0. 097). The mortality of patients that were readmitted more than once (from a total 160 patients, 41 died -25. 6%) was bigger than the mortality of patients readmitted just once (from a total 696 patients, 131 died -18. 96%) (P = 0. 12). The length of stay of nonsurviving readmitted patients in other departments before readmission was higher than the length of stay of survivors (mean 7. 64 days vs mean 5. 71 days). Conclusion Sex and age older than 70 years of patients readmitted to the ICU, readmission during 24 hours, and length of stay in other departments before readmission could be used for simple prediction of mortality of patients readmitted into the ICU. 

The amount of single patient readmissions to the ICU cannot be used as a predictor of death of patients readmitted to the ICU. We abstracted data from the APACHE III database. For each ICU, the SMR and ARR with their 95% confidence intervals (CI) were calculated. ICU performance was categorized as shown in Table 1.
section_name: P468

section_content: When comparing ICUs, if the 95% CI of the SMR or the ARR overlap between the units, the performances were considered similar. If there was no overlap, the differences in performance were considered statistically significant. 

Results During the study period, 12,447 patients were admitted to the three ICUs: 4,334 to the medical ICU, 3,275 to the mixed ICU and 4,838 to the surgical ICU. The predicted mortality rates were 19. 5%, 16. 0% and 9. 0% and the observed mortality rates 14. 8%, 9. 7% and 4. 3% for the medical, mixed and surgical ICUs, respectively. The SMR and ARR in mortality for each ICU are presented in Table 2. 

Conclusions ICU mortality performances assessed by SMR and ARR give different results. The ARR may be a better metric when comparing ICUs with a different case mix. Performances of the prediction models on unseen datasets were analyzed with fivefold cross-validation. Wilcoxon signed-rank analysis was performed to examine differences in performances between prediction models and to analyze differences between real and predicted tacrolimus blood concentrations.
section_name: P470

section_name: P471

section_content: The mean absolute difference with the measured tacrolimus blood concentration in the predicted regression model was 2. 34 ng/ml (SD 2. 51). Linear SVM and RBF SVM prediction models had mean absolute differences with the measured tacrolimus blood concentration of, respectively, 2. 20 ng/ml (SD 2. 55) and 2. 07 ng/ml (SD 2. 16). These differences were within an acceptable clinical range. Statistical analysis demonstrated significant better performance of linear (P < 0. 001) and nonlinear (P = 0. 002) SVM (Figure 1 ) in comparison with linear regression. Moreover, the nonlinear RBF SVM required only seven data components to perform this prediction, compared with 10 and 12

Available online http://ccforum. com/supplements/11/S2 Methods One hundred and fifty-one receiving and deceased donor brace subordinates to kidney transplant. Clinical parameters investigated for every donor were: age, arterial hypertension (≥140/80 mmHg), diabetes, blood values of creatinine. It was chosen to classify as marginal all the donors with age >55 years, and/or hypertension, and/or diabetes, and/or with blood values of creatinine >1. 5 mg/dl, and/or whose death has happened because of one whichever pathology that has determined cerebral anoxia. 

Based on such parameters the donors' borderline was 72/151 (47. 7%), while the optimal was 79/151 (52. 3%). The mean age of the donors was 47. 5 years (range 14-81 years). The population of the 151 receiving optimal and marginal kidneys was constituted of patients judged suitable for the transplant with typical risk factors for a standard population of subjects on dialysis. The mean age of receiving patients was 46 years (range 21-71 years). We have classified receiving based on the outcome of the transplant to 5 years, as: patients alive with transplanted kidney still working, deceased patients, and patients re-entered to haemodialysis. Results Eighty-seven per cent (n = 69) of kidneys transplanted from optimal donors, in fact, have turned out working, 4% (n = 3) have re-entered haemodialysis within 5 years from the surgery, and only 9% (n = 7) have deceased in the same period. Regarding marginal kidney receiving, it has been possible to demonstrate that 72% (n = 52) of such subjects maintained a good function of the transplant, 11% (n = 8) re-entered haemodialysis, and 17% passed away within 5 years of the transplant. Conclusions The difference between the survival of the two receiving groups is not such to justify the exclusion of marginal donors from the 'pool' of potential kidney donors. Considering that, the use of marginal donors can be a valid system in order to supply the lack of organs. Moreover the histological examinations, executed on patterns captured with wedge biopsy before the transplant, can be an effective strategy finalized for the expansion of potential kidney donors. of poor postoperative outcome in lung transplantation and may cause primary graft dysfunction (PGD). A number of processes are thought to contribute to PGD. Relatively little is understood of the role of brain stem death (BSD) in subsequent organ dysfunction. We wished to examine the effect of BSD on the endothelin (ET) axis. Methods Following ethics approval, 14 Wistar-Kyoto rats were anaesthetised, with tracheostomy and arterial and venous cannulation. A 200 µl Fogarty's balloon catheter was inserted via a burr hole into the subdural vault. The balloon was inflated in the experimental group but not the control group. Four hours of positive pressure ventilation were followed by euthanasia and organ retrieval. Lung tissue was stained for H&E for morphology, and alveolar macrophages (AM) were identified by anti-CD68 staining. AM were stained with a monoclonal anti-ET-1 antibody, as well as the polyclonal anti-ET-A and ET-B.
section_name: Results

section_content: Results All animals survived the experiment. There was a significant increase in the ratio of AM to neutrophils (P = 0. 002). 

The ET-1 content on the AM was significantly increased in the experimental group (27. 57 ± 5. 26 vs 7. 01 ± 1. 75, P < 0. 0001). Conclusions In this model, BSD was associated with an increase in the ratio of AM to neutrophils, and there was significant upregulation of the endothelin axis on these AM, as evidenced by raised levels of ET-1, ET-A and ET-B. There may be a role for endothelin blockade in the BSD organ donor. This may increase the yield of organs that can be accepted for transplantation and improve early graft function in the recipient.
section_name: P473

section_content: Prognosis factors in lung transplant recipients readmitted to the intensive care unit Introduction Readmission to the ICU during the same hospitalization is associated with significant morbidity and mortality and results in a longer length of stay and higher costs. There is therefore growing interest to identify reliable predictors for readmission. The aim of our study was to assess the incidence of ICU readmissions, identify predictors of ICU readmission, and determine patient outcome. Methods We performed a retrospective case-control study. The study population consisted of all patients who were discharged alive from our 28-bed surgical, thoracic-surgical and medical ICU in a university teaching hospital in a 1-year period. A case was defined as a patient readmitted to the ICU within 48 hours after discharge. For each case, three control patients were randomly selected from the study population. The following information was collected: demographic parameters and APACHE II score, parameters of hemodynamic, respiratory and renal function, length of ICU stay, duration of invasive ventilatory support (ventilator time), and time between extubation and discharge. To determine a predictive model, covariate selection was done by the two-sample t test, Mann-Whitney test and univariate logistic regression. From significant (P < 0. 10), plausible and clinically relevant variables, a predictive model was generated using multivariate logistic regression. 

Results During a 1-year period 1,635 patients were admitted to our ICU. Of 1,393 patients at risk for readmission, 25 (1. 8%) readmissions occurred in 23 patients. Nine of the 23 (39%) readmitted patients died during their hospitalization, while the overall ICU mortality was 10. 6%. The most important reason for readmission (68% of the cases) was respiratory deterioration. In the univariate analysis, age, ventilator time during first admission and time between extubation and ICU discharge were significant predictors of readmission. In the multivariate analysis, age (OR 1. 1; 95% CI 1. 00-1. 13; P = 0. 03) and ventilator time during first admission (OR 1. 1; 95% CI 1. 00-1. 10; P = 0. 03) were significant predictors, corrected for patient characteristics. Furthermore, patients who were readmitted had a significant longer duration of total (first and second admission) ventilator time (188 vs 106 hours, P = 0. 012), and total ICU stay (400 vs 127 hours, P = 0. 009). Conclusion Patients readmitted to the ICU have significant longer overall ventilator time, ICU stay, and a higher ICU mortality. The ventilator time during first admission (especially beyond 300 hours) is an important predictor of readmission. The time it takes to get patients ready for discharge after extubation also differed significantly. The data suggest that elderly patients who have been ventilated for a long period are at particular risk for readmission and should receive additional care before discharge from the ICU.
section_name: P474

section_content: Intensive care unit readmissions after lung transplantation: epidemiology and outcome Introduction The modified early warning system (MEWS) is a physiological scoring system that identifies patients at risk of deterioration who require increased levels of care [1]. The use of a patient's MEWS score to predict outcome in a high-dependency unit (HDU) has not been previously described. 

Method Approval for the study was granted by the local ethics committee. We reviewed MEWS scores from all patients (n = 2,974) admitted to a six-bed medical and surgical adult HDU in a general hospital from July 2002 to October 2005. The MEWS score was calculated from observations of heart rate, blood pressure, respiratory rate, urine output, conscious level and temperature recorded within 24 hours of admission to the HDU. Results Of the 2,974 patients reviewed, 2,447 patients had sufficient data. Analysis using logistic regression shows a strong relationship between the probability of death and the MEWS score: the odds of death increase by 1. 48 (confidence interval 1. 41-1. 56; P < 0. 001) for each unit increase in the MEWS score. However, there is no reason that these data should follow a logistic form and the estimates of uncertainty around the point estimates from logistic regression are poor. More accurate estimates of the death rate for each of the MEWS scores were achieved using a 'bootstrapping' technique (repeated sampling, with replacement, from the dataset) 1,000 times (see Figure 1 ). The median death rate (%) for each MEWS score was: 3 = 1. 5%; 4 = 0. 7%; 5 = 2. 2%; 6 = 3. 0%; 7 = 3. 0%; 8 = 5. 6%; 9 = 9. 7%; 10 = 13. 3%; 11 = Introduction The purpose of this study was to determine the level of satisfaction of patients and families with the care received in step-down units (SDUs). In an effort to alleviate ICU demand, many centers have opted to provide graded levels of critical care in SDUs. However, there is a paucity of literature as to the effectiveness of care delivered in SDUs. Measures of patient and family satisfaction with healthcare are recognized as valuable tools for the assessment of healthcare delivery including adherence to patient-centered and family-centered quality care. Literature examining patient or family satisfaction in SDUs is limited. Methods We administered a modified version of the previously validated Family Satisfaction with ICU care survey to patients and families of patients who were cared for in the SDUs (18 beds in four separate units) of a tertiary regional referral center. We obtained self-reported levels of patient and family satisfaction with 27 aspects of care related to SDU experience, communication, and decision-making. Responses were converted to item scores, which reflect poor to excellent satisfaction with care (0-100). 

Results A total of 120 patient surveys (60% response) and 99 family surveys (45% response) were completed. Patients had a mean SDU length of stay of 2. 5 days, APACHE II score of 9. 9 and an SDU mortality of 2. 4%.
section_name: P476

section_content: We investigated patient management plans to ascertain the total number made, types of plan, priority, personnel responsible and expected time frame, proportion completed and the causes and consequences of failed plans (on the patient, the family and the critical care service). Methods Over seven consecutive days, details of all consultant determined management plans were recorded by a dedicated nurse auditor. A plan was defined as an identifiable do-able, shortterm action. Data on type, (arbitrary) priority, involved personnel and time frame were noted. The auditor later returned at the end of shift to determine whether plans had been completed in the appropriate time frame (successful plan) or not (unsuccessful plan). For unsuccessful plans, the nurse, senior nurse, senior house officer, fellow and consultant were all independently quizzed on causes and consequences (for patient, family, service) from a predetermined list of possibilities.
section_name: Introduction

section_content: Of 200 plans, 130 were successful, for three plans data were missing and 67 (34%) plans were unsuccessful. Of unsuccessful plans, 36 were completed late, 22 were never completed and nine had missing data. Thirty-six per cent, 34% and 18% of arbitrarily defined high-priority, medium-priority and lowpriority plans were unsuccessful. Most plans were to be actioned by nurse or senior house officer, and 36% and 28% were unsuccessful, respectively. More unsuccessful plans than successful plans were recorded in the computerised notes, 79% vs 67%. Only 40% of data (staff opinions) on perceptions of causes and consequences were gathered. Patient consequences of failed plans included increased ICU stay in 24%, increased morbidity such as risk of inadequate nutrition in 9%, delayed definitive treatment in 7%, delayed weaning in 6%, increased risk of infection in 5% and no impact on patient in 44%. Consequences for family included no impact in 53%, misinformation given in 8%, delayed patient access in 2%, and delayed communication in 2%. Service consequences were bed blocking/increased workload in 20%, delayed admission of another patient in 14%, cancelled elective operations in 4%, and loss of unit capacity and cohesion in 7%. Conclusions We failed to achieve 100% successful plans. Small numbers and failure to gather more than 40% of staff opinions on causes and consequences of failed plans limit this pilot study. Documentation in (electronic) notes did not improve completion of plans. The process and efficiency of care has an impact on at least aspects of morbidity and length of stay, and deserve further study. Introduction For most countries, there are no good estimates for the costs of intensive care (IC) although it is known that the ICU is a major inpatient cost driver. The aim of this study was to estimate the real costs of IC in two hospitals in The Netherlands using a micro-costing methodology. Methods The costing study was undertaken at two hospitals in The Netherlands. We conducted a retrospective cost analysis of 200 consecutive patients admitted to a 32-bed mixed adult ICU at an academic hospital during two periods in 2006: 16 April-15 May and 5 June-23 June. For comparison, we collected detailed data at a general hospital that has a 10 bed-adult general ICU for the period 1 January-1 July 2003. The costs were adjusted to 2005 using the general price index. Both times, we applied a micro-costing approach, implying that all relevant resources were identified and valued at a detailed level. Data on resource use of diagnostics, drugs, fluids, materials, admission and discharge were acquired from the computerized Patient Data Management System in both hospitals. Hotel and nutrition costs were collected from the respective financial departments. These costs were divided by the annual number of patient-days to calculate the cost per day. The NEMS or TISS scores in the academic or general hospital, respectively, were used to estimate nursing time per patient per day. The costs of medical specialists were based on the labour costs and the number of ICU days per year. In the academic hospital, time for consultations of medical staff attributable to each individual patient-day was prospectively collected using patient record forms. These costs we assumed to be comparable in the general hospital in the absence of detailed data. Unit costs of diagnostics and consumables were derived from the financial hospital databases. Labour costs were based on standardised costs per minute, which equalled the normative income divided by the number of workable minutes per year.
section_name: Results

section_content: Estimates of the costs of inpatient-days and nonpatient-related care were based on the annual account for 2005 of the hospitals. Nonpatient-related care (capital, overhead) was appointed to patients using a marginal mark-up percentage.
section_name: P485 Outcome of very old patients on mechanical ventilation

section_content: In the academic hospital the average total costs per ICU day amounted to €1,775, compared with €1,703 in the general hospital. The distribution of the costs by cost component varied.
section_name: Results

section_content: The overall costs per day for IC in an academic hospital were slightly higher than the costs for an ICU day in a general hospital. These derived costs fit nicely to the official reference costs of €1,730 for an ICU day in The Netherlands, which is based on a global top-down approach.
section_name: Conclusions

section_content: C Schnakers 1, J Giacino Results Patients with a haematological malignancy had an ICU mortality of 50%, and a hospital mortality of 58%. Control patients had an ICU mortality of 60%, and a hospital mortality of 67% (statistically nonsignificant). The length of time to admission between the two groups was significantly longer in the haematology group at 12. 4 days, compared with 2. 8 days in the control patients (P < 0. 05). The level of organ support was the same between the two cohorts.
section_name: P488 Does the Glasgow Coma Scale correctly diagnose the vegetative and minimally conscious states?

section_content: We have demonstrated that, for our unit, there was no statistically significant difference in hospital or ICU mortality between the two groups. In fact, the group with a haematological malignancy had a lower mortality than the control group. The presence of haematological malignancy, of itself, does not appear to increase the mortality risk, when compared with a population of patients without haematological malignancy of a similar age, APACHE II score and admission diagnosis.
section_name: Conclusion

section_content: The number of organ failures in oncologic patients admitted to the ICU is a good predictor of mortality. We propose to analyze the association of this variable and quality of life (QOL) aspects in oncologic patients who survived an ICU admission. 

Methods ICU data were prospectively collected from March 2003 to November 2005. Oncologic patients were selected. QOL aspects were evaluated through the analysis of independence to accomplish daily living activities (IADL) after ICU discharge, defined as the patient's ability to walk, eat by mouth, maintain an oriented conversation and bath himself. The number of organ failures was assessed through the SOFA score. Severe organ dysfunction (SOD) was defined if the patient had three or four points in any of the six domains of the SOFA score. According to the number of SOD, patients were divided into two groups: one with two or less SODs and another with three or more SODs. Groups were compared using Fisher's exact test. 

Results Seventy out of 793 patients had an oncologic diagnosis. The mean age was 52 ± 19 years, male gender 56%, medical admission 77%, hematological malignancies 47% and mean APACHE II score 20 ± 8. ICU mortality was 53% and inhospital mortality was 71%. Nine (13%) patients were discharged of the hospital with complete IADL. Mortality in the group admitted with three or more SODs was 100%, while in the other group it was 39% (P = 0. 01, OR 2. 5 95% CI 1. 8-3. 6). During the ICU stay, patients who developed three or more SODs had a higher ICU and inhospital mortality than the ones who did not (89 x 23%, P < 0. 001, OR 7, 95% CI 1. 8-26 and 100 x 53%, P < 0. 001, OR 2, 95% CI 1. 4-2. 6) and a smaller proportion of IADL after ICU and hospital discharge (0 x 22%, P = 0. 04, OR 1. 7, 95% CI 1. 3-2. 2 and 0 x 47%, P < 0. 001, OR 2, 95% CI 1. 4-2. 6). Conclusion Mortality should not be the only aspect analyzed when considering an ICU admission for an oncologic patient. The QOL, including IADL, must be taken into account. A higher number of SODs during the entire ICU stay is associated with higher ICU and inhospital mortality. Beyond this association, a smaller number of SODs may be associated with higher probability of IADL.
section_name: Introduction

section_content: Intensive care unit utilization after esophagectomy R Iscimen Introduction It is good medical practice to communicate with patients regarding their condition and proposed treatment. Communication is essential to allow them to express their concerns and exercise their own autonomy, in a situation where they otherwise may have little control. Poor communication may contribute to unnecessary anxiety or depression. The aim of this audit was to observe whether the doctors communicated with patients on ward rounds. Methods We audited 28 ICU ward rounds. It was noted whether the patient was sedated or not sedated, and whether they had their eyes open or closed. Negative comments were recorded, and defined as comments regarding a patient's poor progress or prognosis made at the bedside during the ward round. We also noted whether the patient was informed that the ward round was in progress, whether they were informed of the plan for the day, and whether any reassurance was offered. The other members of the team were not aware of the audit. Results Twenty-eight ward rounds were audited, a total of 328 patient reviews. The total number of patients with their eyes open was 171, while 157 had their eyes closed. An adverse comment was made during 8. 2% of reviews within earshot of the patient. A negative comment was made on 27 episodes, 13 of these were when the patient was not sedated but had their eyes closed. Four episodes occurred when the patient was not sedated and had their eyes open, while 10 were sedated and had their eyes closed. Of the 171 patients with their eyes open, 74 (43%) were informed that we were the team doing the ward round, while 97 (57%) were not spoken to at the start of the review. Fifty-three (31%) were informed of our management plan for the day and 43 (25%) were offered reassurance. In total, 103/171 patients (60%) with their eyes open were spoken to during the ward round, and we did not speak to 68 (40%). Conclusion On intensive care ward rounds, patients are often not engaged in conversations or allowed to express their concerns. The majority of patients were not offered reassurance or informed about the treatment plan. Improved communication skills may help to lessen patients' anxiety and unnecessary stress both during their stay on ICU and following their discharge. Introduction The postgraduation course had been developed by the Brazilian Critical Care Society (AMIB) to be applied to physicians from all regions of Brazil since 2004. The importance of this 360-hour course is to provide continuous education and to train abilities to make decisions and start treatment. Also, for those who are in ICU practice, to qualify for application of specialist examination. The main objective of this study is to identify who are the doctors that are looking for this course. Methods An opinion poll was collected from the students on the first day of the class course approaching the following aspects: 1. Profile. 2. He/she is attending the course in order to: prepare for the specialist critical care examination (), improve qualification (), work at an ICU (), any other reason if they do not deal with critical care patients (). 3. If he/she works at an ICU: how long (years) and the role (duty, routine or leader). 4. Partners of AMIB (yes) (no); if they have specialist title recognized by the AMIB (yes) (no). 5. If he/she has other postgraduation or residency program. 6. Self-evaluation related to the critical patient knowledge (scales from 1 to 9, considering 9 the highest grade). 7. Interest in the subjects of intensive care medicine (scales from 1 to 9). Results From 2004 to 2005 the AMIB started eight postgraduation courses in different regions of Brazil; 250 students were enrolled; 184 had answered the survey. The average age was 35. 8 years (24-57); 133 men, 51 women. One hundred and five students are attending the course in order to improve their qualification, 87 are studying for the specialist title examination, 58 to work in the ICU and 47 to acquire new knowledge. They considered their main specialties to be: internal medicine (54), intensive care (15), surgery (10) and anesthesiology (seven). Sixtyfive percent work in the ICU (12. 7% are leaders, 19. 5% daily routine, 86. 4% on duty and 6. 8% play all three functions), 6% have the specialist critical care title, 15. 7% are associated with the Brazilian critical care society, 49. 45% have medical residence in another area, 36. 4% have other postgraduations. They selfconsidered around grade 6 for cognitive aspects, procedural skills and competence and near grade 8 for communication and relationship (see Figure 1 ). Cardiopulmonary resuscitation, mechanical ventilation, haemodynamics and neurointensivism are the most desirable subjects. Conclusions Doctors are mainly from the fourth decade, want to improve their qualification, and are usually working in ICUs. The low number of specialists who works in ICU is a reality and there is a need to expand it. The self-evaluation points to problems with knowledge and ability; however, communications and relationships were well adjusted. The diversity of data will assist the AMIB to provide continuous education and qualify doctors to attend the demand of intensivists in Brazil. 2 ) the variation between the different units still exists. Methods We assessed data completeness of a Finnish ICU quality benchmarking database from 1998 to March 2006 containing 93,964 admission records. The data completeness was defined as a ratio of available and required data at ICU admission level. We evaluated the dataset and selected 19 most significant admission scheme variables to be included in completeness ratio calculations.
section_name: P496

section_name: P499 Hospital volume and outcome following mechanical ventilation on the intensive care unit

section_name: P501

section_content: The majority of data (77. 5%) was collected with the manual system and the remaining 22. 5% with an integration software. The mean admission data completeness ratio (CR) increased from 85. 3% at 1998 to 97. 9% at 2005 (P = 0. 01). Between the ICUs, the mean CR varied from 91. 6% to 99. 6% (P = 0. 01). The mean CR of the data collected with the IVT was 98. 7% and with the manual system was 95. 1% (P = 0. 01). The rate of 100% complete records per patient was 48. 7% and it increased from 0. 0% in 1998 to 71% in 2005. Conclusion Data completeness in the FICQC has improved during the study period, although there is still significant variation between ICUs. Improved data completeness and decreased proportion of missing data are most likely due to the increasingly common use of CIS and automated data collection. We conclude that measuring/reporting the amount of missing data is mandatory when data collection and data management procedures for benchmarking are being developed. Introduction In this study we created a database to analyse the incidence and types of critical incidents that occurred during the interhospital transfer of critically ill patients. The transfer of critically ill patients presents important risks and the safety of patients has been shown to be facilitated by the development of standard equipment and specialist teams [1]. The West of Scotland Shock team is a designated regional transfer service based in Glasgow. We are involved in the interhospital transfer of patients and not primary retrieval. A recent study looking at critical incidents during the intrahospital transport of the critically ill highlighted the risks posed, and recommended the monitoring of incidents in order to aid the continuous improvement in patient safety [2]. No similar study has been carried out looking at the interhospital transport of the critically ill patient. Methods The study was a cross-sectional analysis of critical incidents occurring during interhospital transport that were reported to the West of Scotland Shock Team critical incident database set up in September 2005. The information obtained was categorised into: (a) where the incident took place, (b) type of incident, (c) written description of events, (d) outcome (potential or actual harm to the patient) and (e) designation of the staff member reporting the incident. Results A total of 199 transfers were performed over the 6-month period. Thirty-four critical incidents were reported. Twenty-four (70%) incidents took place before, seven (21%) during and three (9%) after transfer. No patients sustained actual harm, 29 (85%) were perceived by the reporter to have suffered potential harm and the most common cause of this were delays in the transfer. No potential or actual harm was perceived in five (15%) of the incidents. Fifty-three per cent of events were reported by senior house officer grade and 47% of incidents were reported by a specialist registrar. Only one incident was reported by a nurse on the team. Conclusions Interhospital transport of critically ill patients can pose important risks. In our study no actual patient harm occurred although most incidents had the potential to cause harm. The majority of incidents were caused by system-based factors. This database has allowed us to perform continuous service development and education of staff.
section_name: Results

section_content: Acknowledgements This study was supported by grants from the Canadian Institutes of Health Research and Physicians Services Inc. of Ontario, and unrestricted grants from AztraZeneca Inc., and Bayer Inc. Acknowledgements This study was supported by grants from the Canadian Institutes of Health Research and Fresenius-Kabi, Germany. Acknowledgement Research project MZO 00179906. References 1. Saner FH, et al. : Eur J Anaesth 2006, 23: 766-771. 2. De Backer D, et al. : Am Heart J 2004, 147: 91-99. Acknowledgement We thank Gruppo Italiano per la Valutazione degli Interventi in Terapia Intensiva for their valuable help.

section_name: P258

section_content: Muscle versus liver mitochondrial respiration in experimental three-hit endotoxemia E Borotto 1, D Tüller 1, S Krähenbühl 2, D Mettler 1, J Takala 1, S Jakob 1 1 University Hospital Bern, Switzerland; 2 Introduction No perfect severity score exists to predict ICU mortality, thus the search for new systems is still a preoccupation. Hypothesis Use of many severity of illness scores simultaneously improves mortality prediction.
section_name: P258

section_content: An open prospective observational study as part of the APRiMo project [1]. The study period was January 1996-September 2004. Inclusion criteria were critically ill obstetric patients and ICU length of stay >24 hours. Exclusion criteria were those of the used scores. The main outcome of interest was the survival status at ICU discharge. The database was divided into two samples: development and validation datasets. Development database patients were chosen randomly (n = 414) and the remaining patients composed the validation dataset (n = 229). A multivariable logistic regression model was developed to predict mortality associating the Acute Physiology and Chronic Health Evaluation II score [2], Simplified Acute Physiology Score II [3], Admission Mortality Prediction Model (MPM-H0) and Day 1 Mortality Prediction Model (MPM-H24) [4]. Discrimination and calibration were assessed by goodness-of-fit C-hat statistics and area under the ROC curve. The developed model was then tested in the validation dataset. Good discrimination was retained if C-hat statistics P > 0. 1 and good calibration if area under the ROC curve > 0. 8.
section_name: Patients and methods

section_content: Six hundred and forty-three patients enrolled. The overall mortality rate was 11. 51%. The new model predicted accurately 99% of survivors and more than 60% of nonsurvivors.
section_name: Results

section_content: The 'multiscore' model seems to refine prognosis. This is partly due to mixing of new evaluated parameters. Testing the latest developed generations of scores and also organ dysfunction systems could be interesting. Introduction Patient survival in neurological intensive care units (NICUs) may be obvious; however, there is currently little evidence regarding the longer term outcome of these patients. In this study the 1-year survival of NICU patients has been defined. Methods Between April 2004 and April 2005, all patients admitted to the NICU requiring ≥24 hours of ≥2 organ system support were identified (n = 175). The year following admission was divided into three phases -early (0-30 days), middle (31-90 days) and late (91-360 days) -and mortality was recorded. Data were analysed using Kaplan-Meier and log-rank analysis. 

Results Patients were admitted from many sources; interhospital transfers (n = 90), neurosurgical admissions (n = 26), medical admissions (n = 36), and emergency admissions (n = 15). Reasons for admission included haemorrhage (n = 66), trauma (n = 52) and neoplasm (n = 19). Ninety-one patients (52. 0%) spent less than 7 days on the NICU and 84 (48%) required ≥7 days. Overall survival was 70. 9% at 30 days and 61. 1% at 1 year. There was no significant variation between the young (<60 years) and older (≥60 years) groups (62. 6%, n = 115 vs 58. 3%, n = 60, P > 0. 5). 

Nor was there a difference between those receiving two organ support and those receiving ≥3 organ support (62. 1%, n = 66 vs 60. 6%, n = 109, P > 0. 5). Mortality (deaths/30 days) varied dramatically between the early, middle and late phases (29. 1% vs 3. 2% vs 0. 9%, P < 0. 001). Conclusions Although mortality is high during the first 30 days of neurological critical illness there is a significant plateau in the survival curve; patients surviving beyond the initial phase tend to survive long term. Larger studies may be beneficial to further evaluate subgroup variation in the survival curve profile. 

Behavioral assessment remains the gold standard to monitor the level of consciousness. However, about one-third of patients diagnosed with a vegetative state are actually conscious (or in a minimally conscious state). We compared the ability of the famous Glasgow Coma Scale (GCS) and other standardized behavioral scales to correctly diagnose the vegetative state in an acute (intensive care and neurology ward) and chronic (neurorehabilitation) setting. The male:female ratio was 2. 18:1. 0, and the average age of death was 42. 9 years. A length of stay before death of 1 week or less occurred in 59. 6%. Forty-seven per cent of families were seen between 2 and 4 months after the death of their relative. The issues most commonly raised were specific questions about the patient (56. 2%), review of information in the notes (34. 8%), complaints (23. 6%), clarifying misunderstandings (18%) and contacting other health professionals (21. 3%).
section_name: Conclusion

section_content: We describe the results of a bereavement follow-up service for families whose relatives died on the critical care unit at University Hospital of Wales, Cardiff. In total, 5. 7% of families took up the service offered. These were usually the families of younger than average male patients, who died with a critical care stay of less than 1 week. We believe that by answering questions still troubling the families 2-4 months after death, we can assist them with their grief. We also believe that this follow-up service by providing further communication can resolve some difficult issues before they develop into formal complaints.
section_name: Conclusions

section_name: P495

section_content: The number of heart-beating donors in The Netherlands is decreasing. This decrease is only partially compensated for by an increase of nonheart-beating donations, resulting in an increasing shortage of donor organs, especially of donor hearts and lungs. In 2005 compared with 2004 the number of patients waiting for a donor heart increased from 38 to 50 (32%). In lung donation the increase was 37% (from 79 to 108). One approach to reduce this shortage is to maximize the number of organs per donor by optimisation of donor treatment in the ICU. Methods We investigated the possibilities for improvement of donor management in our ICU by a retrospective study in 37 heartbeating organ donors hospitalised in our ICU from 1993 to 2005. There was no protocol for the treatment of organ donors in our institution.
section_name: Introduction

section_content: The heart was donated in 18 of 37 patients (49%). Lung donation was possible in only eight of 37 donors (22%). Most hearts and lungs were rejected for transplantation for valid reasons. In some patients there was room for improvement: in two of the three cases where hemodynamic instability impeded heart and lung donation (one dying from subarachnoidal bleeding and one from ischemic cerebral infarction), hemodynamic instability was closely associated with the moment of cerebral death. In three further patients heart donation was not carried out because of wall movement abnormality or electrocardiogram abnormalities. None of Available online http://ccforum. com/supplements/11/S2
section_name: Results

section_content: them had previous cardiac disease. All three had disturbances in cardiac rhythm closely related to the occurrence of cerebral death. Two of these three patients also developed neurogenic pulmonary edema. We speculate that in all five patients the instability leading to the decision not to perform heart and lung donation was caused by excessive sympathic stimulation at the time of cerebral death leading to impaired myocardial function and neurogenic pulmonary edema. These disturbances may be reversible within a few hours. Introduction Critical care research involves data from many countries, but critical care resources in these countries are unknown. We hypothesized that there are large differences in critical care resources between countries.
section_name: S200

section_content: We identified original research articles on critical care in three high impact factor journals (N Engl J Med, JAMA and The Lancet) published from 2001 to 2005. A list of the countries where data collection occurred was extracted. Eight countries contributed to ≥10 studies. A collaborator in each country was asked to provide baseline critical care information for their country from 2005, or as close to that date as possible. 

Results Sixty-two studies involving data from 51 countries were identified. Eight countries contributed data to ≥10 studies during this time period: the USA (26 studies), France (18), the United Kingdom (14), Canada (13), Belgium (12), Germany (10), The Netherlands (10) and Spain (10). Relevant data on baseline hospital and critical care resources for the eight countries identified are presented in Figure 1 (data from Canada not available). Adult ICU beds ranged from 3. 3/100,000 population in the United Kingdom to 24. 6 in Germany, and represented a range of 1. 4% of all acute care hospital beds in the United Kingdom to 11. 0% of all beds in the USA. Conclusions Many countries contribute substantially to critical care research. However, the underlying critical care resources vary dramatically among these countries. 

Available online http://ccforum. com/supplements/11/S2
section_name: Methods

section_content: Baseline critical care resources in eight countries. *Extrapolated from survey data, not full national data.
section_name: Figure 1 (abstract P506)