ICU A Description of the Nottingham Head Injury Register 1993 - 2002: 1672 Cases of Traumatic Brain Injury Alison

Chalmers, Hina Pattani, Gordon Fuller, Paddy Yeoman Queens Medical Centre, Nottingham University Hospitals NHS Trust. United Kingdom Traumatic brain injury is the leading cause of death and disability among young adults in the developed world yet funding for head injury research is low. Many advances in neurosurgical care have resulted from data collected from large databases. The Nottingham Head Injury Register was established in 1993 with the key aims of providing an opportunity for audit, research and health care planning. Data was collected prospectively on all patients admitted to the QMC with a diagnosis of moderate or severe traumatic brain injury (Glasgow Coma Score of 12 or less). Data was collected from a total of 1672 patients. 23% of patients were under the age of 16 years and the average age of patient was 32. 75% of patients were male. CT data was available on 1378 of our patients. 561 patients had a focal lesion visible on CT. 310 (22%) had a subdural haematoma, 128 (9.3%) had an extradural haematoma and 123 (8.9%) suffered either an intracerebral haematoma or contusion. The remaining 817 patients (59%) had a diffuse cerebral injury. Overall, 52% of patients treated at the QMC had a favourable outcome at 12 months (Glasgow Outcome Score 1 and 2). This abstract describes the baseline characteristics of patients admitted to the QMC with moderate or severe traumatic brain injury over a nine year period. This large, validated database is a valuable resource to advance neurocritical care.

ICU A prospective evaluation of routine use of PercuTwist controlled rotating dilation. Aniello De Nicola, Maria Jos Sucre, Antonio Coppola, Francesco Paolo Riti, Carmen De Angelis Department of Anaesthesiology and Intensive Care Medicine, San Leonardo Hospital. Castellammare di Stabia (Napoli), Italy. To assess the feasibility and safety of PercuTwist tracheotomy technique. Endoscopy was used in all cases and evaluated as an added safety measure in reducing complications. Between 2005 and 2007, endoscopically guided percutaneous dilatational tracheotomy were conducted in 100 consecutive adult patients using the single-use dilator screw-tap (PercuTwist, Teleflex). The tracheotomy was performed within the first week of a prolonged mechanical ventilation. The following parameters were recorded: the mental space, the time needed for the procedure and the intraoperative and postoperative complications. The procedure was contraindicated in uncorrectable coagulopathy. All patients were ventilated with LMA or endotracheal tube on 100% oxygen and vital signs were continuously monitored. Tracheotomy was carried out after endoscopic transillumination of the 2nd and 3rd tracheal cartilage. The mental space was < 2 fingerbreadths in 5% patients. Tracheotomy was performed within 10.5 min (range 6 to 24 min). Only 10 complications were noted: bleeding (2), mucosal lesion of the trachea (2), cannula false insertion (1), desaturation and others (3). None of these complications was considered to be serious. The absence of severe complications are attributable to the use of bronchoscopy. There was a significant association between the rate of complications with use of endotracheal tube in reduced mental space patients versus the use of LMA. Under appropriate endoscopic view, the Percutwist method results quickly done and a fast procedure: this reduces the time between the decision and the performance of tracheotomy. The rotational dilatation technique was associated with a low complication rate, was safe in the ICU setting and was an integral part of our intensive care treatments. Frova G, Quintel M. A new simple method for percutaneous tracheostomy: controlled rotating dilation. A preliminary report. Intensive Care Med. 2002 Mar, 28(3):299-303. De Leyn P et al. Tracheotomy: clinical review and guidelines. Eur J Cardiothorac Surg. 2007 Jun 22.

ICU A Routine of Follow-Up Meetings Post Death with family members of patients that died in the Intensive Care Unit is appreciated. Maria Kock, Caroline Berntsson, Anders Bengtsson Department of Anaesthesiology and Intensive Care, Sahlgrenska University Hospital/East, Gothenburg, Sweden ICUs staff may have an impact on the grieving process in families in bereavement. A routine with one Follow-Up Meeting Post Death for families of patients that had died suddenly in our ICU was introduced 2001. We wanted to evaluate if families appreciated the routine. It was done as an anonymous uncoded questionnaire. The first part related to the Follow-Up Meeting Post Death. The second part inquired if we could contact the family member in the future. The questionnaire was sent to 84 family members of 56 deceased patients. 46/84 family members answered. 78% were satisfied with their meeting. 67 % got answers to their questions. The majority wanted the meeting to take place within 6 weeks of death. Only 7% preferred meeting only one person. 91% rated the doctor as important at these meetings. The social worker was rated more important than the assistant nurse. 91% wanted to discuss the cause of death. Other highly rated issues were the medical care, and if the patients outcome could have been influenced by the family. 91% thought that we should continue to offer Follow-Up Meetings Post Death. 37% did not want us to contact them again for further studies. Our evaluation shows that the Follow-Up Meetings Post Deaths were appreciated. As the questions were of medical matters the doctors play an important role. Many family members did not want to be contacted for further evaluations. This must be respected in the planning of future studies. The low frequency of answers must, however, be considered. Follow-Up Meetings Post Death are appreciated. The presence of the doctor at the meeting is important. Curtis J.R. and Rubenfeld G.D. Managing Death in the Intensive Care Unit, Oxford University Press 2001 (ISBN 0-19-512881-8)

ICU Apneic oxygenation combined with extracorporeal arteriovenous carbon dioxide elimination provides sufficient gas exchange in experimental lung injury Niels Dalsgaard Nielsen, Benedict Kj?rgaard, Jacob Koefoed-Nielsen, Christian Overgaard, Anders Larsson 1, 3 & 5: Anaesthesia Research Unit, North Denmark Region, Aarhus University Hospital, Aalborg, Denmark 2: Dept. of Thoracic Surgery, Aalborg Hospital, Aarhus University Hospital, Aalborg, Denmark 4: Dept. of Anaesthesiology, Aarhus University Hospital, Aarhus Sygehus, Denmark We hypothesized that continuous high airway pressure without ventilatory movements (apneic oxygenation), using an open lung approach, combined with extracorporeal, pumpless, arterio-venous, carbon dioxide (CO2R) would provide adequate gas exchange in acute lung injury. The aim of this study was to test this hypothesis in a lung injury model using pigs of human adult size, to mimic the O2 consumption and the CO2 production of adult patients. In eight anesthetized, tracheally intubated and mechanically ventilated pigs (85-95 kg), lung injury was induced by repeated lung lavage. Thereafter the tracheal tube was, after a lung recruitment maneuver, connected to 20 cmH2O continuous positive airway pressure (FiO2 = 1.0) for oxygenation of the blood. A pumpless membrane lung (iLA, NovaLung, Germany) was connected in an arteriovenous shunt for CO2R. Cardiac output (CO), mean arterial blood pressure (MAP), and the arteriovenous shunt flow were monitored. PaO2, PaCO2 and pH were obtained every 30 minutes for 3.5 hours. PaO2 was 61 (53-66) kPa (median and IQR) throughout the experiment. The O2 uptake via the lungs was 185 (164-212) mL/min, whereas the O2 uptake via the Novalung was 4 (011) mL/min. PaCO2 increased exponentially towards a maximum value just below 8 kPa. The CO2R via the Novalung was 178 (148-178) mL/min and pH was 7.35 (7.33-7.37) during the experiment. CO was 8.9 (7.2-10.5) L/min and MAP was 85 (79-89) mmHg. The high, stable PaO2 suggests that 20 cmH2O airway pressure was sufficient to prevent alveolar collapse and the stabilization of PaCO2 and pH at physiological levels indicate that the Novalung provided sufficient CO2 elimination. In this porcine lung injury model, apneic oxygenation with arteriovenous CO2R provided sufficient gas exchange and stable hemodynamics, indicating that the method might have a potential in the treatment of severe ARDS. The membrane lungs were kindly provided by Novalung, Germany.

ICU Bispectral index monitoring during propofol treatment of refractory status epilepticus in the intensive care. Tadeusz Musialowicz, Esa Mervaala, Reetta Klvinen, Ari Uusaro, Esko Ruokonen, Ilkka Parviainen Department of Anaesthesiology and Intensive Care Medicine, Department of Clinical Neurophysiology and Department of Neurology, Kuopio University Hospital, PO Box 1777, 70211 Kuopio, Finland The aim of the present study was to compare the bispectral index and suppression ratio values with the EEG burst suppression pattern when the depth of anesthesia was titrated to burst suppression level monitoring by continuous EEG. The hypothesis was that BIS monitoring can be used to guide the level of anesthesia in the treatment of refractory status epilepticus (RSE). Ten patients with RSE were enrolled into the study. Continuous EEG and BIS recording were started after admission to ICU using a BIS A-2000 XP monitor. We used a predefined protocol for the RSE propofol treatment (1). Data are reported as mean and 95% confidence interval. Spearman coefficient and receiver operating characteristic (ROC) cuvers and respective areas under the curve (AUC) were used for statistic analyses. 85 periods lasting 3 minutes during anesthesia before burst suppression and 85 periods lasting 3-6 minutes during burst suppression and twelve periods during epileptic activity lasting 3-10 minutes were analysed. There were excellent correlation of bispectral index (r2= 0, 9, p= 0, 001) and suppression ratio (r2= 0, 89, p= 0, 001) with EEG burst rate per minute. The AUC for the BIS ablity to detect burts suppresion pattern in the EEG was 0, 99. The mean bispectral index during burst suppression pattern in EEG was significantly lower [17 (CI 13-16)] compared with the mean before burst suppresion [37, CI 37-42), (p=0, 001)]. BIS also significantly increased (p= 0, 001) during epileptic activity in the EEG (64, CI 53-74) compared with values during burst supression pattern. We conclude that BIS correlates well with cEEG in the monitoring the depth of anesthesia in the treatment of RSE with propofol. BIS may give also useful information about abnormal epileptic EEG activity.

ICU Blood transfusion practices in critically ill patients among physicians working in Intensive Care Units in the English-speaking Caribbean Patrick Toppin, Hyacinth Harding, Georgiana Gordon-Strachan University Hospital of the West Indies Kingston Jamaica There has been growing evidence that a more restrictive transfusion practice is beneficial in critical illness. This study seeks to assess the practice of in ICUs in the English speaking Caribbean given limitations in blood products and general funding. A questionnaire was administered to physicians working in ICUs in Barbados, Trinidad, Bahamas and Jamaica. Physicians indicated appropriate haemoglobin levels for transfusion in four clinical scenarios: multiple trauma, gastrointestinal haemorrhage, severe sepsis and acute myocardial infarction. The effect of severity of illness and age were assessed by modifying the APACHE II score and the age in the scenarios. Response rate was 91%. The multiple trauma scenario had the lowest mean transfusion threshold (7.13 g/dL) and the myocardial infarction scenario the highest (8.68 g/dL). Transfusion thresholds for the four scenarios were significantly different (p< 0.0001). Physicians were more likely to transfuse elderly patients and those with higher APACHE II scores (p<0.0001). Factors influencing decision included current literature (60%), shortage of blood products (26%) and the risk of disease transmission (23%). Strategies employed to decrease blood transfusion included use of haematinics (52%), reduced phlebotomy (34%) and erythropoietin (26%). 47% of physicians adopted a restrictive transfusion practice. There was significant variation between the various centres. Many critical care physicians in the English-speaking Caribbean have adopted a restrictive transfusion practice in keeping with current international recommendations. Given the severe limitation in blood products protocols encouraging reduced phlebotomy and a restrictive transfusion practice may be useful in further reducing utilization of blood products without increasing expenditure. Hebert, P.C.et al. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med, 1999. 340(6): p. 409-17. Corwin, H.L., et al. Crit Care Med, 2004. 32(1): p. 39-52. Hebert, P.C., et al., Crit Care Med, 2005. 33(1): p. 7-12

ICU Cannulation of the internal jugular vein: Are left sided catheters associated with more complications due to catheter tip malposition? Bee Hooi Tan, Chow Yen Yong, Jahizah Hassan Department of Anaesthesia and Intensive Care Penang Hospital, Malaysia Unsatisfactory central venous catheter (CVC) tip location can lead to serious complications. Right-sided CVCs should be positioned in the SVC above the cephalic limit of the pericardial reflection (CLPR). However, left-sided CVCs should lie in the lower SVC or upper RA to avoid abutment on the vessel wall. The CLPR cannot be seen on plain CXR but has been shown to lie just below the carina. As a quality improvement exercise, we performed a prospective cohort study of CVC tip position and the associated complications using the carina as a reliable surrogate landmark. Patients who were referred for ICU care from March 2007 - September 2007 and required a triple lumen CVC were enrolled in this study. The marking of the catheter at the skin was recorded. All post CVC insertion CXRs were reviewed. We measured the vertical distance of the CVC tip above or below the carina and the angle of the distal 1cm of the tip to the vertical. All patients were monitored for potential complications. 97 patients were enrolled into this study. 47% (31/66) of right-sided catheter tips were placed below the carina. However, only transient arrhythmias were encountered during guide wire insertion. 48% (12/25) of left-sided catheters were placed above the carina with an acute angle (>40). Complications encountered were abutment of catheter tips on the vessel wall, hence inability to aspirate blood from the distal lumen, transient arrhythmias and one significant morbidity with pneumo-haemothorax and massive bleeding from subclavian artery puncture. Left sided catheters are associated with higher complication rates due to the acute angle formed with the SVC wall and insufficient length to lie within the SVC. Therefore, right sided approach should be preferred and a longer (25 cm) CVC should be used for left sided insertion.

ICU Changes in Pulmonary Artery Catheter Use 2001-2006 Thomas Higgins, Maureen Stark, Lisa Manganaro, William McGee Critical Care Division, Baystate Medical Center, Springfield MA USA (Higgins, McGee) Project IMPACT, Bel Air, MD USA (Stark and Manganaro) A recent study (1) found that pulmonary artery catheter (PAC) use decreased by 65% in medical ICU admissions between 1993-2004. As that study relied on administrative database, we examined the Project IMPACT database (2) for clinical corroboration. The percentage of Project IMPACT ICU patients (2001-2006) receiving PACs was tallied for all patients in the database, those admitted to medical-surgical (vs. specialized) units, noncardiac elective surgical patients, and medical patients. The Mortality Probability Model (MPM-II) (3) was used to gauge severity of illness. 322650 pts were admitted to 182 ICUs at 130 hospitals with 158447 admitted to combined medical-surgical ICUs. 124026 pts carried primary medical diagnoses, and 50093 were non-cardiac elective surgical patients. 35356 (11.0%) of all ICU admissions received a PAC, 2.8% in medical patients, 12.4% in elective surgical patients. Utilization rates over time shows the greatest decline in PAC use in elective surgical patients (from 17.5% to 8.3%), and that the absolute decline has been much smaller in medical patients (from 3.9 to 1.9%) and within combined medical-surgical ICUs (from 9.3% to 6.5%). MPM-II survival probability in medical-surgical units was 82% in 2001, 81% in 2002, and 80% from 20032006. Project IMPACT data confirms the decline in PAC use noted in the U.S. Nationwide Inpatient Sample (1). The greatest absolute decline is in the elective surgical population, representing 15% of ICU admissions, but use in medical patients has also declined. Severity of patient illness does not explain the change. Further study is needed to determine if hemodynamic monitoring is shifting to less-invasive devices. 1. 2. 3. Wiener RS, Welch HG, JAMA 2007, 298: 423-429 www.cerner.com/piccm Project IMPACT website, accessed 8/29/07 Lemeshow S, Teres D, Klar J et al: JAMA 1993, 270:2478-2486

ICU Clinical Outcomes and Prognostic Factors of Chronically Ill Patients in a Medical Intensive Care Unit in Korea Sung-Su CHUNG, Younsuck KOH, Kwangha Lee, Sang-Bum Hong, Chae-Man Lim 1) Dept. of Anesthesiology Chonnam National University Hospital, Gwangju, KOREA 2-5) Division of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, KOREA Chronically critically ill (CCI) patients are defined by the patients who require prolonged mechanical ventilation and various medical resources for over 21 days in an intensive care unit (ICU) with the reversible underlying diseases. The aims of this study were to describe the clinical profiles and outcome variables of CCI patients, to be defined by the requirement of prolonged mechanical ventilation for over 21 d in an ICU with reversible underlying diseases Retrospective cohort study. One hundred forty-one patients (5.8%) were classified as CCI patients between July 1, 2003, and June 30, 2005. Their ICU and hospital lengths of stay (LOS) were 42.9 36.4 and 83.9 100.5 d. ICU and 6-month cumulative mortality rate were 42.6 & 75.9%. Significant negative correlation was observed between the SOFA score on the 21st day and MICU and hospital LOS. There were significant differences between non-survivors and survivors for APACHE II scores, SOFA scores, and simplified TISS scores as well as the delta value between SOFA scores on the 3rd day and the 21st day. Multiple logistic regression analysis showed the SOFA score on the 21st day was the most predictive factor of CCI patients survival. When the SOFA score cutoff value on the 21st day was 8 , the mortality rate was 90% (sensitivity 71%, specificity 77%). In medical ICU, the ratio of CCI patients was 5.8% and a 6-month cumulative mortality rate was 75.9%. In CCI patients, it is suggested that the SOFA score on the 21st day is the most important prognostic factor. If the SOFA score on the 21st day is above 8, it could be a useful indicator when a step-down of therapeutic level is considered.

ICU Community-acquired Meningitis David Watson, Penny Willson 1. Consultant Anaesthetist, Royal Infirmary of Edinburgh, Department of Anaesthesia, Critical Care and Pain Medicine, 51 Little France Crescent, EH16 4SA, Edinburgh, Scotland, UK. 2. Specialist Registrar, Royal Infirmary of Edinburgh, Medical Microbiology Department, 51 Little France Crescent, Edinburgh, EH16 4SA, Scotland, UK. 10 year retrospective data for adults admitted to the ICU, diagnosed with communityacquired (CA) bacterial meningitis analysed. Neurological conditions, head injury, immunocompromised state and risk factors were researched. Mortality in meningitis is high as are neurological sequelae. Diagnostic criteria for acute meningitis included the history, pyrexia, nuchal rigidity, GCS score < 15. Data for January 1997 January 2007 were collected from the hospital database (Ward Watcher) APACHE II, SAPS II, radiological, haematological, LP, blood culture (BC), CSF-PCR and a database constructed (MS Excel 2003). Comparisons between admission diagnosis, causative organism and confirmatory microbiological evidence were reviewed. Outcomes included death, survival and neurological complications. Data for 28 adults (range 17 80 years, median 49), male 16 (57%) with ICU admission evidence for CA meningitis were analysed. 23 (93 %) were ventilated. Seizures occurred in 5 (18%), pyrexia (? 38C) 18 (64%), GCS (range 3 14, median 8), mortality 8 (28.6%). Pre-LP CT was undertaken in 25 (89.2%). Streptococci predominated S. suis (1) and S. pneumoniae (12), N. meningitides (8) groups B and Y (1), S. aureus (1). B. anthracis sepsis was revealed at post-mortem (1). In 5 cases no organism found despite CSF pleocytosis (1), incomplete CSF data (WBC count, PCR) in 11 (39%). Risk factors included pre-existing neurological events 6 (21%), chronic otitis interna 3 (11%) and immunocompromised states 4 (14%). Deafness, tinnitus, diplopia (VI palsy), vertigo, telogen effluvium were sequelae 9 (32%). Meningitis has varied risk factors, presentation and sequelae. van de Beek D, de Gans J, Tunkel AR, Eelco FM, Wijdicks EFM. Community-acquired bacterial meningitis in adults. N Engl J Med 2006, 354: 44-53. Scottish Intensive Care Society Audit Group, UK Royal Infirmary of Edinburgh Intensive Care Unit, Scotland, UK Royal Infirmary of Edinburgh Medical Microbiology Department, Scotland, UK

ICU Comparison of different types of early warning system in patients who go on to develop cardiac arrest Maria Armstrong, Alex Stone, David King Southend University Hospital, Essex, UK Different types of early warning system are in use worldwide to identify in-patients at risk of developing critical illness and to prompt timely intervention. They include single parameter trigger and weighted aggregate scoring systems. A retrospective case-note analysis of documented deteriorating physiology of in-patients who went on to develop a cardiac arrest, was undertaken, comparing amongst other criteria lead time and frequency of triggers. High sensitivity of a system has been identified as a feature of primary importance, hence this was determined. Southend multiparameter, single trigger, system (SEWS) was compared with the widely used, more complex, aggregate weighted modified early warning score (MEWS). After exclusions 57 episodes on 56 patients comprising 215 sets of observations were included. SEWS was triggered in 46 of the 56 patients (sensitivity 82%). MEWS triggered for 25 of the group (sensitivity 45%). Average lead times provided were 14.5 and 11.6 hours respectively for SEWS and MEWS. Average number of triggers per patient were 2.9 and 2.1 for SEWS and MEWS. Single parameter systems have been criticised for lack of sensitivity compared to weighted aggregated scoring systems. This does not appear to be the case in our study, selecting out those whose endpoint is cardiac arrest. We suggest that as our study takes into account real standards of observation recording, the increased sensitivity demonstrated may make it more appropriate for level 0 care than the more complex aggregate scoring systems, which are more commonly protocol in UK hospitals. We acknowledge that our study is retrospective and does not address specificity. Systematic review and evaluation of physiological track and trigger warning systems for identifying at-risk patients on the ward. H Gao et al, ICNARC, Intensive Care Med. Apr 2007, 33(4):667-79

ICU C-reactive protein and response to Activated Protein C. David Higgins, Sarah Mapplebeck, Edward Breeze, John Kinnear Southend University Hospital NHS Foundation Trust Essex, UK In the PROWESS (1) study interleukin-6 was used as a marker of inflammation. This assay is not available in many centres and we have used a more widely available inflammatory marker (C-reactive protein) to assess if the severity of the inflammatory response can guide selection of patients to receive APC 20 patients with >1 sepsis induced organ failure had CRP levels measured prior to starting APC treatment. For all patients APACHE II, risk of death, and outcome were recorded. Table of results OUTCOME Died Survived NUMBER 12 8 APACHE II 27 33 Risk of Death 62% 61% CRP 207 214

APC is an expensive treatment for severe sepsis that partly acts via its anti-inflammatory properties. We have used CRP to quantify the severity of the inflammatory response to see if this is related to the effectiveness of APC. There was no correlation between severity of inflammation and response to this treatment 1. Efficacy and safety of recombinant human APC for severe sepsis. Bernard G et al. NEJM 2001, 344, 699-709

ICU Critical care outreach team: audit of referrals, interventions and outcomes Seema Quasim, Muang Kyi Good Hope Hospital, Rectory Road, Sutton Coldfield, B75 7RR The outreach service provides clinical support and critical care skills for the acute ward areas. We have audited referrals, interventions and outcomes for outreach patients. Prospective data on all patients referred to the outreach service was carried out using Excel software. During April 2006, 98 referrals were made to the outreach service. Median length of outreach follow up was 2.06 days and median length of in-patient stay was 21 days. Mortality at discharge was 20%. There were 45 follow-ups (2 of which required readmission to level 2 care). Of the 53 non-follow ups: -24 had a documented MEWS score of 3 or more -3 patients died -4 patients had a DNAR decision made -15 patients were admitted to critical care (7 to level 3) We have further analysed the referrals by specialty, referring person and interventions performed on the first visit. Critical care outreach has been criticised for being enthusiastically embraced and funded in the UK without adequate evidence of benefit. Follow up of critical care patients remains an important part of the service, providing support to both patients and ward staff. A significant proportion (17%) of outreach referrals resulted in admission to critical care, and a further 5% resulted in DNAR decision (thus avoiding cardiac arrest calls). References Audit Commission. Critical to Success. London: Audit Commission, 1999. Department of Health. Comprehensive Critical Care: a Review of Adult Critical Care Services. London: Department of Health, 2000. Pittard AJ. Out of our reach? Assessing the impact of introducing a critical care outreach service. Anaesthesia, 2003, 58: 882-885 Ball C, Kirkby M, Williams S. Effect of critical care outreach team on patient survival to discharge from hospital and readmission to critical care: a non-randomised population based study. B Med J 2003, 327: 1014-1017.

ICU Differences in the gas distribution in volume controlled mechanical ventilation compared to pressure controlled in multialveolar lung model JOSE Navarro-Martinez, Roque Company, Joaquin Roca, Josefina Del Fresno, Maria Jesus Rivera, Sebastian Utrero, Francisco Martinez Anestesiology Department, Hospital General de Alicante. Spain. Exists quite a controversy as to whether ventilate a patient with pressure controlled ventilation (PCV) over volume controlled ventilation (VCV).The goal was to determinate if PCV offers advantages in terms of pressure and alveolar distribution in a multialveolar compartment lung model compared to a VCV. The lung model was a simulator with 3 compliances of 25 or 12, 5 ml/cmH20 and 4 resistances of 5 and 20 cmH2O/l/seg. 64 situations were simulated. We used as respirator the TEMEL Supra, . The respirator setting was:TV of 500cc, I/E 1:2, RR of 10 breaths/min and ZEEP. The flow in the VCV was 60 and 20l/min. The pressure in the VCP was the lower to reach the tidal volume fixed. We used a endtracheal tube of 7, 5 ID. VCV Flow 60 VCV Flow 20 MOUTH ALVEOL 1 ALVEOLI 2 ALVEOLI 3 Ppeak Pplateau Pmean Ppeak Pplateau Pmean Ppeak Pplateau Pmean Ppeak Pplateau Pmean *** p<0, 01 PCV does not offer advantages over the VCV in terms of alveolar pressure, obtaining worse results in the redistribution parameters. The VCV guarantees a tidal volume fixed, whereas the PCV maintains a constant pressure, but the tidal volume turns on the compliance and resistance and may create a situation of hypoventilation. 18 + 4 10,2 + 1,5 5,6 + 0,6 11,4 + 3,5 10,11,6 0,5 + 0,01 8,3 + 2,7 101,7 0,3 + 0,01 10,2,2,5 10,21,5 0,37 + 0,02 13, 52,2 10,5 1,5 4, 80, 6 11,12,5 10,251,6 0,250,08 9, 62 10,21, 2 0,130,04 10,61,5 10,31,5 0,160,06 VCP 11 + 2*** 10.6 + 1,5 4,4 + 0,5*** 12 + 2* 101,8 0,3 + 0,01*** 9,6 + 2* 9,81,8 0,17 + 0,04*** 10,1+ 1,6 10,11,6 0,22 + 0,02***

ICU Early PercuTwist tracheotomy improve the outcome from post-traumatic acute respiratory distress syndrome. A case report. Aniello De Nicola, Maria Jos Sucre, Antonio Coppola, Natalia Grossi, Carmela De Angelis, Giuseppe Donnarumma Department of Anaesthesiology and Intensive Care Medicine. San Leonardo Hospital. 80053 - Castellammare di Stabia, Napoli, Italy To present and discuss the rationale and possible benefits of early Percutwist tracheotomy in post-traumatic acute respiratory distress syndrome. A 23-year-young patient who had sustained a complicated fracture of shaft of the femur and blunt thoracic trauma non diagnosticated presented after 3 days during orthopedic unit stay severe hypoxaemia and psychomotor agitation. The body computed tomography showed bilateral pulmonary contusion and substantial bilateral atelectasis. In ICU, the patient was accidental tracheally extubated in three times during the nursing care. Oxygenation and lung mechanics did not improve with low tidal volume ventilation using high positive endexpiratory pressures (PEEPs). Because of a few sign of returning consciousness and a predictable difficult weaning from mechanical ventilation, we decided to perform a bedside Percutwist tracheotomy on day 5. Oxygenation and lung compliance improved rapidly and aeration of the entire lung was confirmed by computed tomography 7 days after the tracheotomy. The tracheostomy tube was removed, the tracheal stoma was covered with a dressing and the patient was transferred again in ortopedic unit. The closure stoma was ended after 5 days spontaneously. The patient recovered completely and was discharged after 10 days. Patients with post-traumatic respiratory failure seem to most readily respond to early Percutwist tracheotomy and could thus benefit from the reduce of recovery days. Moreover the probability of infections and ventilator associated complications may be reduced. The stomal opening created by the Percutwist technique allows might close quickly after the removal of the tracheostomy tube. In the case we report, Percutwist procedure is easy to do and the better alternative for airway management of critically ill patients. 1. 2. Pettiford BL and et. The management of flail chest. Thorac Surg Clin. 2007,17(1):2533 Schreiter D et al. Alveolar recruitment with positive end-expiratory pressure. Crit Care Med. 2004,32(4):968-75

ICU Early prediction of tracheotomy during critical illness Denise Veelo, Anne-Willemijn Buddeke, Jan Binnekade, Dave Dongelmans, Marcus Schultz Department of Intensive Care, The Academic Medical Center, Amsterdam, The Netherlands Several studies on timing of tracheotomy (early [e.g., < 3 days after admission] versus late [> 10 days]) are presently being performed. Early in the course of critical illness , however, it may be difficult, if not impossible, to determine the need to proceed with tracheotomy. We explored how well ICUcaregivers are able to predict a tracheotomy among intubated and mechanically ventilated ICUpatients. Setting: A 28bed closed-format ICU of a universityaffiliated hospital. Design: Observational study on the incidence of tracheotomy with daily distributed questionnaires among attending ICUphysicians. Patients with an expected ICU stay > 3 days were included. Predictions of tracheotomy (using visual analog scale from 0 [this patient will certainly not need a tracheotomy during this ICUstay] to 10 [this patient will certainly need a tracheotomy]). A VAS of 810 was defined as a positive prediction. Seventyfour patients were included, of which 11 patients received a tracheotomy (incidence of tracheotomy 1.6 per 100 ICUdays). Tracheotomy was performed after mean (SD) 10.3 (6.1) days. Physicians (intensivists, fellow-intensivists and residents) predicted tracheotomy 2.3 [95%confidence limits (CL) 1.1/3.4] VAS points higher for patients who were finally tracheotomized. The Relative Risk of receiving tracheotomy when intensivists made a positive prediction was 3.66 [95%CL 1.3 /10.3], P = 0.02. Patients that received tracheotomy had higher VAS scores, although differences with non tracheotomized patients were small. Accordingly, patients who eventually will proceed with tracheotomy might indeed be recognized early.

ICU Early prognostic indices in transition to spontaneous breathing after long-term mechanical ventilation Prof. Temelkov Atanas, Marinova Ralica Alexandrovska University Hospital, ICU-Center of Acute Respiratory Insufficiency 1 G. Sofiiski street, Sofia, Bulgaria Determination of predictive indices, which are significant for withdrawing ventilator support after long term mechanical ventilation (>7 days) is often difficult to be achieved during the early stages of weaning process. We studied 45 mechanically ventilated patients, attempted for transition to spontaneous breathing. The patients were divided into two groups : group A (n=38) in which two hours test for spontaneous breathing by T-piece weaning was successful, and group B (n=7) in which T-piece weaning was unsuccessful. The BICORE-CP 100 monitor was used to control the following parameters : respiratory rate/tidal volume ( f/Vt), occlusive pressure (P0.1), Inspiratory time/Tidal volume ratio (Ti/Ttot), Pressure time index (PTP), and work of breathing (WOBp) Patients in group A, who tolerated two hours spontaneous breathing succeeded in gradual withdrawal of mechanical ventilation, while patients in group B, whose T-piece weaning was unsuccessful failed in weaning of mechanical ventilation. The predictive value of bedside weaning parameters which were measured is different. The indices WOBp and f/Vt are the most sensitive and have the greatest predictive value (p<0, 001). They determine further strategies for weaning after long-term mechanical ventilation. Levy M, Mijasaki A "Work of breathing as a weaning parameter in mechanically ventilated patients", Chest 1995, 108, 1018-1020 Petros AJ., Lamond CT "The Bicore pulmonary monitor." Anaesthesia 1993, 48, 985-988

ICU Effects of dexmedetomidine and propofol on inflamatory responses, and intraabdominal pressure in severe sepsis, preliminary study Muhittin Tasdogan, Dilek Memis, Necdet Sut, Mahmut Yuksel Trakya University, Medical Faculty, Department of Anaesthesiology and Reanimation.Edirne TURKEY We evaluated the effects of intravenous infusion of propofol and alpha-2-adrenoceptor agonist dexmedetomidine, on serum cytokine levels[Interleukin(IL)-1, IL-6, tumor necrosis factor(TNF)-a], and on intraabdominal pressure, in patients suffering from severe sepsis after abdominal surgeries. 40 patients were included to the study either the bolus dose infusion of propofol(n=20 Group P)1 mg/kg over 15 mins followed by a maintenance 1-3 mg/kg/hr (n=20, Group P) or bolus dose of dexmedetomidine was 1 microg/kg/h over 10 min followed by a maintenance 0.2 -2.5 microg/kg/h(n=20, Group D)24 h. infusion. Biochemical and hemodynamic parameters, cytokin levels and intraabdominal pressure were recorded before start of the study at 24th and 48th hr. Group D compared to Group P,TNF-a levels were found significantly lower at 24th h(14.664.40 vs 21.2111.37pq/ml respectively) and at 48th h(21.2515.85 vs 46.5525.99 pq/ml respectively) in group D(p<0.05), IL-1 levels were found significantly lower at 24th (5.030.15 vs 6.232.09 pq/ml respectively) and at 48th hr(5.010.37 vs 6.422.76 pq/ml respectively, p=0, 041) in group D(p<0.05), IL-6 levels were found significantly lower at 24th h(253.1103.6 and 511.3374.8 pq/ml respectively) and at 48th h. (343.5193.4 and 503.7306.4 pq/ml respectively) in group D(p<0.05). Intraabdominal pressure also was found significantly lower at 24th hr.(12.355.84 vs 18.12.84 mmHg respectively) and at 48th hr (13.96.15 vs 18.73, 46mmHg respectively) in group D(p<0.05). Biochemical and hemodynamic parameters, did not differ significantly between the groups(p<0.05). We found that dexmedetomidine infusion decreases the TNF-a, IL-1, IL-6 levels and intraabdominal pressure compared to propofol infusion 1. Taniguchi T, et al.Crit Care Med 2004, 32:1322-6.

ICU Epidemiology of adverse events in a tunisian intensive care unit Massoudi Karim, Frikha Nabil, Friaa Mahdi, Kaouch Nizar, Fnaiech Fakhreddine, Charfeddine Ahmed, Mebazaa Mhamed Sami, Ben Ammar Mohamed Salah. Anesthesiology, ICU and ED, Mongi Slim Hospital, La Marsa, Sidi Daoued, Tunisia. Patients in the intensive care units are at high risq of adverse events. The aim of this descriptive study was to evaluate the nature, incidence, and impact of such adverse events in a an intensive care unit in order to promote a continuous quality improvement activity. A prospective epidemiologic study was undertaken over a period of six months (from November 2005 to may 2006) in a medicosurgical intensive care unit of a university hospital of Tunis. Al patients admitted in the intensive care unit for more than 24 hours were included. Adverse events, their nature and timing of accurencewere recorded. The impact in terms of morbiditu an mortality superimposed were also evaluated. Among 250 patients admitted, 102 ruled the inclusion criteria. The incidence of adverse events was 59.8% (61 / 102 ). 222 episodes of adverse events were recorded ( an average of 2.2 per patient). Metabolic episodes were the most common adverse events noted (52%). The other events were haemodynamic, respiratory and infectious. The iatrogenic origin was not retained for the metabolic events exept for episodes of hypoglycemia or hyperglycemia. A moderate to strong evidence for management causation was retained or the other events with a high preventability This study revealed a high incidence of adverse events in our intensive care unit. The metabolic events, because of the facility of their screening are the most representative. The other events are frequently iatrogenic with high preventability. An assurance quality improvement program is needed to be implented. 1. 2. Giraud T. Crit Care Med 1993 , 21 : 40- 51. Trunet P.Rean Soins lntens Med Urg 1987 , 3 : 15-8.

ICU Epidemiology of Severe Sepsis in Intensive Care Unit Hulya Sungurtekin, Demet Okke Pamukkale University Severe sepsis and sepsis are associated with mortality rates as high as 30 to 60%. The aim of this study was to investigate the numbers, clinical characteristics and outcomes of admissions who met criteria for severe sepsis in the intensive care unit (ICU). A retrospective analysis of prospectively collected data for ten month period. Inclusions criteria were patients with diagnosis of severe sepsis at the time of admission or hospitalization in ICU. The criteria used for severe sepsis based on the ACCP/SCCM definitions. SAPS II at admission and SOFA scores of 1st, 3rd and 3rd days of severe sepsis were recorded. In this 10 month study, 315 patients admitted to ICU. 15% (n=48) of patients met severe sepsis criteria in ICU. Most were nonsurgical (n=28) and the most common organ system dysfunction were seen in the cardiovascular and respiratory systems. 18 patients had more than one organ failure. Mortality rate of the severe sepsis patients was 50%. Although age and mean length of stay didnt different between survivor and nonsurvivor, all scores were significantly higher in the nonsurvivors (Table, p<0.05 between groups). Table I SAPS II SOFA 1 SOFA 3 SOFA 7 Survivor (n=24) 51.915.1 10.84.7 9.94.5 10.04.1 Nonsurvivor (n=24) 64.916.3* 14.53.0* 14.13.0* 15.12.4*

In our hospital severe sepsis is common, frequently fatal and presents a major challenge for clinicians. Mortality increases with high scores of SAPS II and SOFA. Padkin et al. Crit Care Med 2003, 31:23322338

ICU Expression of integrin av6 in rats with ventilator-induced lung injury and the attenuating effect of synthesized peptide S247 Qingping Wu, Ping Gui, Shanglong Yao Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China To investigate the expression of integrin av6 in ventilator-induced lung injury (VILI) and to assess the ability of RGD-peptidomimetic agent S247 to attenuate VILI in rats. adult male Sprague-Dawley rats were randomly divided in to three groups: 1) controls (C group: n=6): no ventilation. 2) high tidal volume(H group: n=6):40 ml/kg tidal volume, 0 cmH2O of positive end-expiratory pressure (PEEP) for 4 hours, 40 breaths/min, FiO2=0.21.3) high tidal volume with S247(HS group: n=6):receiving the same ventilation settings as H group and also S247 before ventilation. Expression of the integrinav6 was determined by real time RT-PCR. Besides the lung histologic examination, Wet-to-dry weight ratio , total protein level and counts of white blood cell(WBC) in bronchoalveolar lavage fluid (BALF) were performed, concentrations of macrophage inflammatory protein-2 (MIP-2) and tumor necrosis factor-alpha (TNF-a) in BALF were also detected by enzymelinked immunosorbent assay (ELISA). mRNA levels of the integrinav6, the wet-to-dry weight ratios, WBC counts and concentrations of protein, TNF-a in BALF were significantly different among three groups(p<0.05 or p<0.01). These results suggest that pulmonary epithelial integrins are involved in the pathogenesis of VILI, RGD-peptidomimetic agent S247 can attenuate VILI in rats. 1. 2. 3. Sheppard D. Functions of pulmonary epithelial integrins: from development to disease. Physiol Rev 2003, 83(3):673-86. Shannon KE, Keene JL, Settle SL. Anti-metastatic properties of RGDpeptidomimetic agents S137 and S247. Clin Exp Metastasis 2004, 21(2):129-38. Miller LA, Barnett NL, Sheppard D, et al. Expression of the beta6 integrin subunit is associated with sites of neutrophil influx in lung epithelium. J Histochem Cytochem 2001, 49(1):41-8.

This study was supported in part by a grant 2005AA301C23 from Science & technology Department of Hubei China to Q Wu (Grant #: 2005AA301C23) and a grant from the National Natural Science Foundation of China to Dr. S Yao (Grant #: 30571787).

ICU Impact Of Early Antibiotics On Severe Sepsis Are We Doing A Good Job? shahlasiddiqui, nawalsalahuddin, junaidrazzak, adeelraza Aga khan university, Karachi, Pakistan Despite improvements in technology and health care 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. The objective of this study was to assess the promptness of antibiotic administration to patients presenting with sepsis and the effects on survival and length of hospitalization Consecutive, adult patients presenting with Systemic Inflammatory Response Syndrome (SIRS) to the emergency department of the Aga Khan University hospital were enrolled in a prospective, observational study from February to June 2006. Source of sepsis, timing and appropriateness of antibiotic administration, resuscitative measures in the ER were recorded. The patient was followed until death or discharge. Univariate, multivariate regression modeling and one-way ANOVA were used to examine the effects of various variables on survival and for significant differences between timing of antibiotic administration and survival, two-sided p values <0.05 were considered significant. One hundred and eleven patients were enrolled. Severe sepsis was present in 52% patients, the most frequent organism isolated was Salmonella typhi (30%). Overall mortality was 35.1%. One hundred (90.1%) patients received intravenous antibiotics in the Emergency room, average time from triage to actual administration was 2.48 ( 1.86) hours. The timing of antibiotic administration was significantly associated with survival (F statistic 2.17, p 0.003).Using a Cox Regression model, we were able to demonstrate that survival dropped acutely with every hourly delay in antibiotic administration. On multivariate analysis, use of vasopressors (adjusted OR 23.89, 95% CI 2.16, 263, p 0.01) and Escherichia coli sepsis (adjusted OR 6.22, 95% CI 1.21, 32, p 0.03) were adversely related with mortality. We demonstrated that in the population presenting to our emergency room, each hourly delay in antibiotic administration was associated with an increase in mortality.

ICU Initial experiences with activating recombinant factor vii (rfviia) at the cirrhotic patient with upper gastrointenstinal tract bleeding Mirjana Sosolceva, Slavica Stojanova, Tanja Trojic, Marija Licenovska Clinic Of Surgery "St.Naum Ohridski" 11 Oktomvri bb 1000 Skopje Macedonia Europa The recombinant activating factor VII (rFVIIa) has prohaemostatic effects in hemorrhagic patients with coagulation abnormalities. Cirrhotic patients have low values of coagulation factors, particularly factor VII. The bleeding from the upper gastrointestinal tract (UGIB) is a complication of cirrhosis which may induce lethal triad and lead further to irreversible shock.The hypothesis was tested that rFVIIa may be efficient to the standard and ednoscopic therapy for control of UGIIB. In 46 year cirrhotic patient with UGIB from, endoscopy with sclerosation was performed in the initial 12 hours. Pharmacological therapy was started with somatostatin, subsequently with thrombin, fibrinogenic adhesive, freshly frozen plasma and cryoprecipitate. Hematological tests (thrombocytes, protrombine time, PTT, D-Dimmers, values of factors II, V, VII and IX and fibrinogen) were monitored on daily basis. In two successive days we administered 8 bolus doses of 10 g/kg rFVIIa i.v. UGIB was controlled in the first 24 hours from the initial dose of rFVIIa and the following days, the need for blood transfusion, FFP, trombocites was determined upon administration of rFVIIa. The effect of rFVIIa was evident: 24 hours upon administration of the second dose, repeated endoscopy did not indicate active bleeding. The recurrent bleeding has not occurred, not even in the following 5 days. The reduced demand for blood, FFP and thrombocytes was significant, as well as for cryoprecipitate. In spite of the stopped bleeding, the lethal outcome in the patient resulted from severe ARDS and subsequent MOF. Conclusion: Even though the final result in the cirrhotic patient and UGIB was unfavorable, the effect of rFVIIa with discontinuation of the coagulation cycle was evident, without recurrent bleeding. The therapy with rFVIIa was delayed, lethal triad was present, and the additional dose was not available. This initial examination suggests that rFVIIa may be used in cirrhotic patient with varicous bleeding.

ICU Is it necessary to measure cardiac output during a fluid challenge? Challenging the dogma Barbara Ceradini, Philippe Welter, Leonardo Gottin, Jean-Louis Vincent Department of Intensive Care at the Erasme University Hospital in Brussels, Belgium Department of Intensive Care at the Policlinico G.B. Rossi in Verona, Italy Fluid resuscitation is the first-line therapeutic measure used to improve the hemodynamic status of critically ill patients. There are several techniques to estimate cardiac output and today the thermodilution technique using the pulmonary artery (PA) catheter is considered as the most reliable one. However, it is not sure that cardiac output monitoring during fluid challenge (FC) has a really clinical usefulness. This is a prospective observational study in a multidisciplinary Department of Intensive Care. We studied the response to 68 FC in 40 patients, monitored with a PA catheter and an arterial catheter. The procedures were divided into three groups according to the main indication: arterial hypotension (group 1), tachycardia (group 2), or oliguria (group 3). CO/CI response was defined positive by an increase at least of 10%. In the first group of 32 FC: 15 increased their blood pressure by at least of 5 mmHg responders, and, 17 did not. In the responders, CO increased = 10% in 67% cases (CI in 53%). In the second group of 5 FC, a reduction in heart rate = 5/min was observed in all the cases, but an increase in CO and CI = 10% was observed only in 50% of these patients. In the third group of 19 FC, an urinary output > 20 ml/h was observed in 16 procedures, among them 63% got also an increase in CO (CI in 50%). We evaluated the variations in CO and CI in a mixed population of medical and post-surgical patients during FC for any intervention. Our data, using a PA catheter, indicated that measurements of CO were not really helpful in this context of FC, and suggested that CO is never measured very accurately but rather estimated.

ICU Ischemic preconditioning attenuates lung injury induced by intestinal ischemia reperfusion. the role of phospholipases a2. Efthimios Avgerinos, Constantinos Kostopanagiotou, Nikolaos Kopanakis, Ioanna Andreadou, Marilena Lekka, Vassilios Smyrniotis, George Nakos, Georgia Kostopanagiotou. 2nd Dept of Surgery, Medical School, University of Athens, Greece 2nd Dept of Anaesthesiology, Medical School, University of Athens, Greece ICU, Medical School, University of Ioannina, Greece A pivotal role of phospholipases A2 (PLA2) and platelet-activating factor-acetylhydrolase (PAF-AcH) in lung injury induced by intestinal ischemia-reperfusion (IIR) has been shown. The objective of this study was to investigate the potential protective effect of gut ischemic preconditioning on the acute lung injury (ALI) with emphasis on PLA2 and PAF-AcH alterations. Wistar rats were submitted to IIR. They were randomly allocated to 3 groups: Group 1: 45min of ischemia followed by 4 hours (h) of reperfusion, Group 2: 45min of sham ischemia followed by 4 hours (h) of reperfusion and Group 3: Three cycles of ischemia for 4min and reperfusion for 10min followed by 45min of ischemia and 4h of reperfusion. Bronchoalveolar lavage fluid (BALF) was obtained from the right lung and its biochemical (protein, PLA2, PAF-AcH) and cytological characteristics were determined. Plasma malonyldialdehyde (MDA) was measured as a marker of lipid peroxidation. Pretreatment with ischemic preconditioning significantly (p<.05) reduced alveolar - arterial O2 gradient values, wet to dry lung ratio, BALF protein and PLA2 but not PAF-Ach. A significant reduction of plasma MDA was revealed. Histologic lesions of both intestine and lung did not show significant improvement in the preconditioning group. Ischemic preconditioning confers a protective effect on the lung injury that might prove to be a simple and effective strategy for the amelioration of IIR remote injury. This alleviating effect can be attributed partly to the reduction of systemic oxidative stress and BALF PLA2. 1. 2. Kostopanagiotou G., et al. Acute lung injury in a rat model of intestinal ischemiareperfusion: The potential time depended role of Phospholipases A2. J Surg Res 2007 in press Moore-Olufemi S.D., et al. Ischemic preconditioning protects against gut dysfunction and mucosal injury after ischemia/reperfusion injury. Shock 2005,23:258-63

This work was supported by the research unit of the 2nd Department of Surgery of the University of Athens.

ICU Linezolid administration improves functional capillary density and attenuates leukocyte adherence in the intestinal microcirculation during experimental sepsis Christian Lehmann, Kirsten Utpatel, Eva Janke, Daniela Saeger, Thomas Issekutz*, Sara Whynot, Orlando Hung, Michael Murphy. Department of Anesthesia, *Department of Microbiology and Immunology, Dalhousie University, Halifax, Nova Scotia, Canada The benefit of antibiotic therapy in sepsis is beyond all questions. However, little is known about the direct effects of antibiotics upon the inflamed microcirculation. The toxins released by antibiotics-induced bacteriolysis may aggravate - even if only temporarily - the alterations in the septic microcirculation. Therefore, the goal of our study was to investigate the acute effects of linezolid, a synthetic oxazolidinone antibiotic, frequently used in severe gram-positive sepsis, on microcirculatory parameters using intravital microscopy. A total of 40 male Lewis rats were randomly assigned to four groups (n=10): sham surgery (SHAM), experimental sepsis (colon ascendens stent peritonitis CASP, [1]), CASP+LIN and SHAM+LIN. Following 15 hours of observation the animals of the CASP+LIN and the SHAM+LIN groups received 25 mg/kg linezolid intravenously. One hour (16 hours) later all animals underwent intravital microscopy of the intestinal wall. LIN administration in septic CASP rats increased mucosal (+62%) and muscular (longitundinal: +30%, circular: +37%) functional capillary density and attenuated the rolling behaviour (-26%) and the number of firmly adhering leukocytes (-22%) in the V1 venules of the intestinal submucosa compared to untreated CASP animals (p<0.05). The results suggest, that linezolid protects microvascular perfusion as measured by functional capillary density and reduces leukocyte activation. In addition to the results of microbial sensitivity testing, a specific knowledge of the potential effects exerted upon the microcirculation is important in order to detect possible side effects of antibiotics. Acute linezolid administration did not worsen the intestinal microcirculation in experimental sepsis. In contrast, an improvement of the intestinal microcirculation could be observed. Therefore, linezolid treatment may be a preferred choice in the antibiotic therapy of gram-positive sepsis. 1. 2. Lustig M, et al.: Shock. 2007,28(1):59-64. Patel R, et al.: Antimicrob Agents Chemother. 2001,45(2):621-3.

The scientific support of Brent Johnston and the technical assistance of Nancy McGrath is gratefully acknowledged.

ICU Mechanical stretch induces PTX3 release by alveolar epithelial cells in vitro Qingping Wu, Huaqing Shu, Ping Gui, Shanglong Yao Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China To investigate the effect of mechanical stretch on PTX3 expression and release in human alveolar epithelial cells(A549). We exposed cells grown on collagen 1 BioFlex plates to square cyclic stretch at 0.3Hz using the Flexercell system with 20% elongation of cells. After stretching, conditioned media were collected and analyzed by Western blotting. Real-time PCR of mRNA extracted from stretched cells was performed. On the other group, cells were pretreated with small interfering RNA of PTX3 before stretch .Apoptosis and viability of the cells following treatments were routinely monitored. 1) cyclic stretch led to increased gene expression and release of PTX3 from lung epithelial cells , 2) stretch can induce apoptosis and necrosis in alveolar type II cells. 3)PTX3 expression was significantly reduced with small interfering RNA. 4) PTX3 levels correlated with severity of apoptosis and necrosis of A549. These results suggest that PTX3 may be an important mediator for tissue damage and play an important role during ventilator-induced lung injury. 1. Dos Santos, C. C., B. Han, C. F. Andrade, X. Bai, S. Uhlig, R. Hubmayr, M. Tsang, M. Lodyga, S. Keshavjee, A. S. Slutsky, et al. DNA microarray analysis of gene expression in alveolar epithelial cells in response to TNF-a, LPS, and cyclic stretch. Physiol. Genomics 19: 331342, 2004

This work was supported by the National Natural Science Foundation of China. The authors thank their colleagues at the Institute of Applied Mechanics, Taiyuan University of Technology for technical help. This work was supported by the National Natural

ICU Nanoparticle Gene Array: The Future of Bedside Pathogen Detection? Scott Ahlbrand, Nader Pourmand, Shan Wang, Niaz Banaei, Brooks Rohlen, Joe Hsu, Nancy Federspiel, Andrew Patterson. Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA Stanford Genome Technology Center, Palo Alto, CA, USA Department of Materials Science and Engineering, Stanford University, Stanford, CA, USA Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA Emergence of drug resistant pathogens occurs frequently in the Intensive Care Unit (ICU). This issue is problematic for critical care physicians because there are now several organisms that can only be effectively treated with a limited number of antimicrobial agents. One strategy for preventing emergence of multi-drug resistant bacteria is to use only narrow spectrum antibiotics directed at culprit pathogens identified using rapid bedside detection devices. We previously developed a nanoparticle gene array designed to detect genomic material at significantly lower concentrations than conventional gene arrays. We hypothesized that a nanoparticle gene array would be sensitive enough to detect infectious pathogens at concentrations as low as 500 fentomolar. We also hypothesized that we could design nanoparticle array probe sets capable of distinguishing common ICU pathogens from other organisms. We generated a nanoparticle gene array on which oligonucleotide probes were attached to a spin valve detector. We tested the ability of the array to detect genomic material at concentrations as low as 10 picomolar. We then attempted to design probe sets using DNA sequences unique to Pseudomonas aeruginosa using an iterative algorithm and 10 published genome sequences. Our data suggest that the nanoparticle array may be capable of detecting pathogens at concentrations as low as 500 fentomolar. Our data also suggest that 7 probe sets may be capable of distinguishing Pseudomonas aeruginosa from other pathogens. We have developed a gene array that may obviate the need for amplification of genomic material by polymerase chain reaction prior to labeling and hybridization. This advancement could facilitate development of a bedside ICU device capable of identifying pathogens in sputum, blood, urine, and cerebrospinal fluid within minutes. Our initial findings suggest that enough data is available in the public domain to design nanoparticle array probe sets capable of identifying common ICU pathogens.

ICU Optimization of Blood Pressure Management with Vasoactive Medications using Horizon Trends Karen Giuliano, Greg Raber, Tara Drew, Jody Case, Dawne Hillsgrove 1, 2 Philips Medical Systems, Andover, MA 3, 4, 5 Concord Hospital, Concord, NH The management of blood pressure using vasopressor therapy is a routine practice in critical care. Most current bedside physiologic monitoring systems rely on audible alarms which trigger when the patients blood pressure drops below the lower alarm threshold , often resulting in undesirable fluctuations in blood pressure. Little has been published regarding titration practices and the degree of compliance with a given blood pressure target. The purpose of this study was to describe the practice of vasopressor titration in a group of critically ill patients using the standard audible alarm. That practice was then compared to vasoactive titration which was enhanced by using an innovative display on the bedside monitor called Horizon Trend. Fifty critically ill patients receiving vasoactive medications for blood pressure support were used as study participants. Group 1 used audible alarms for blood pressure management and Group 2 used Horizon Trends in addition to the audible alarms. Continuous blood pressure measurements were recorded using a laptop computer attached to the monitoring system. Demographic data on the study participants were also collected. Results support that the use of Horizon Trends does have an impact on the clinical practice of vasoactive medication titration. Subjects in the Horizon Trends group (Group 2) had a higher mean arterial blood pressure (73.3mmHg vs 69.1) with less variation (standard deviation 5.5mmHg vs 8.1). In addition, the Horizon Trends group also spent significantly more time within their target blood pressure range (82.8% vs 64.4%), and with less variability (standard deviation 17.3% vs 25%). Horizon Trends displays the data needed for blood pressure management using vasoactive medications in a way that appears to improve clinical practice. More data is needed to further support this finding. The authors would like to acknowledge the support of Jill Donahue, RN, MSN, Concord Hospital

ICU Outcome of maternal admissions to intensive care unit at King Faisal hospital Betty Khainza King Faisal Hospital Kigali There is no study in the developing countries reviewing indications and outcomes of maternal ICU admissions . Objectives were to find out reasons for maternal ICU admissions, outcome , complications and factors associated with poor outcome With permission from the hospital research committee we prospectively reviewed all mothers after 28 Weeks amenorhoea to 6 weeks post delivery admitted to the general ICU over a 33 month period Jan 2005 to September 2007. Data was collected using a questionnaire. Diagnosis, duration of the illness before admission, referring unit, complications , interventions, maternal outcome was recorded. Statistical analysis done by EPI INFO 2000. There were 66 (11.2%) maternal admissions out of 558 adult admissions. 20 (30.3%) were referred from other hospitals. The majority were post delivery haemorrhage 24.2% and hypertensive disorders 21.2%. Of the 46 patients from within all had good recovery, all were admitted within an average of 6 hours of critical illness compared to 43.5 hours among those referred from other hospitals. Of the 20 from outside 10 (50%) died and 1 had permanent disability. The mortality was 10/66 (15.1%) compared to the general ICU mortality of 21%. 4/10 (40%) of the patients who died had central nervous system complications followed by severe post partum sepsis 2/10, severe haemorrhage 2/10, the rest were cardiac failure 1/10 and respiratory failure 1/10. DIC was common in haemorrhage while multiple organ failure was associated with death. The mean duration of stay was 4.3 days Early icu maternal admissions have a good outcome. sepsis are associated with poor outcomes. CNS complications and maternal Kilpatrick SJ, Matthay MA,

Obstetric patients requiring critical care. A five-year review. Chest 1992 May,101(5):1407-12. The hospital administration and ICU staff

ICU P.aeruginosa clinical ICU strains antibiotic resistance Vlad Smirnov, Georgi Ilukevitch Belarusian Medical Postgraduate Academy, Minsk, Belarus The goal of our study was to perform a P.aeruginosa ICU clinical strains resistance analysis in Minsk. We performed retrospective multicentred epidemiological trial included 10ICUs in 10 Minsk hospitals performed from 01.01.2005 to 30.06.2007. 917 clinical isolates of P.aeruginosa were obtained from patients with nosocomial infections. Identifications and antibioticograms were made by the disk diffusion method on MH agar and by using ATB Expression system (BioMerieux). The results were interpreted according to the CLSI standard. Our study confirmed P.aeruginosa as the most common cause of nosocomial infections in Minsk hospitals ICUs (21, 28%, n = 917). All P.aeruginosa strains in our study were resistant to grand majority of antibiotics and sensitive only to polymixin B (R=16, 7%) and imipenem (R = 14, 9%). The resistance to the other antibiotics was: meropenem 64, 6%, amikacin 43, 2%, cefepime 78, 7%, ceftazidime 48, 1%, pefloxacin 88, 9%. Weve noticed very fast increasing of P.aeruginosa resistance to beta-lactams, chinolones and chloramfenicol after using meropenem monotherapy. Resistance to imipenem/cilastatin remained the same through all the period of examination and didnt depend on any previous antibiotic course. We suppose a MexAB-OprM system activation by using meropenem and confirm imipenem and polymixinB as the most appropriate antimicrobials for P.aeruginosa nosocomial infections. 1. 2. 3. N Masuda, E Sakagawa, and S Ohya Outer membrane proteins responsible for multiple drug resistance in Pseudomonas aeruginosa. Antimicrob Agents Chemother. 1995 March, 39(3): 645649 David M. Livermore, Of Pseudomonas, porins, pumps and carbapenems Journal of An-timicrobial Chemotherapy (2001) 47, 247-250 Hyunjoo Pai, 1, * Jong-Won Kim, 2 Jungmin Kim, 3 Ji Hyang Lee, 1 Kang Won Choe, 4 and Naomasa Gotoh Carbapenem Resistance Mechanisms in Pseudomonas aeruginosa Clini-cal Isolates Antimicrobial Agents and Chemotherapy, February 2001, p. 480-484, Vol. 45, No. 2 Wang C.Y., Jerng J.S., Cheng K.Y., et al. Pandrug-resistant Pseudomonas aeruginosa among hospitalized patients: clinical features, risk-factors and outcomes. Clin Microbiol Infect 2006, 12:63-8.

4.

ICU Performance of oxygen delivery devices when the breathing pattern of respiratory failure is simulated Malcolm Sim, Pamela Dean, John Kinsella, Roland Black, Martin Hughes 1 Clinical Lecturer, 2 Senior House Officer, 3 Professor, 5 Honorary Clinical Senior Lecturer, University Department of Anaesthesia, Level 2, Queen Elizabeth Building, Glasgow Royal Infirmary, Glasgow G31 2ER, UK 4 Consultant in Anaesthesia and Intensive Care, Royal Devon and Exeter Hospital, Devon EX2 5DW, UK There is little published data on the performance of oxygen delivery devices in respiratory failure. We wished to assess the performance of such devices when the breathing pattern of respiratory failure was simulated. 14 volunteers underwent basic spirometry. An oxygen sampling line was inserted into the nasopharynx. FiO2 was measured at rest breathing 4 litres / minute (l/min) oxygen (Hudson mask) and then breathing 12 and 24 l/min humidified oxygen (Hudson mask). A trauma mask was applied and 15 and 80 l/min oxygen administered. Finally, a Vapotherm 2000i was tested. This allows nasal administration of humidified oxygen up to 40 l/min. Bandages were applied around the chest wall until FEV1 was reduced by > 50% and respiratory rate increased to > 25/ minute. Measurements were repeated. FiO2 pre and post simulation of the breathing pattern of respiratory failure: Hudson mask: 4 l/min (0.44 to 0.33, -23.9%, p<0.001), 12 l/min humidified (0.58 to 0.47, -17.8%, p<0.01), 24 l/min humidified (0.72 to 0.63, -12.2%, p<0.01). Trauma mask: 15 l/min (0.68 to 0.65, Not Significant (NS)), and 80 l/min (0.86 to 0.87, NS) Vapotherm 2000i at 40 l/min, humidified, via nasal prongs (0.89 to 0.89, NS). Low flow devices produce a predictably low FiO2 that falls with increased respiratory rate and reduction in expiratory pause. High Flow oxygen delivery devices currently in use either produce a lower FiO2 than expected, or are not humidified. Gases that are not humidified dry the upper airway and cause difficulty expectorating [1]. We have demonstrated that the Vapotherm 2000i can generate an FiO2 of 0.89 using humidified gases. It may have an increasing role in critical care to provide medium to long term high FiO2 therapy. 1. Irwin RS and Rippe JM. Irwin & Rippes Intensive Care Medicine, 5th edn. Lippincott Williams & Wilkins, 2003.

ICU Pneumonia after major abdominal surgery Tania Choupina, Fernando Abelha Department of Anesthesia, Hospital de So Joo, Porto, Portugal Pneumonia is an important complication of major abdominal surgery. The aim of this study was to identify predictors and factors associated with the occurrence of postoperative pneumonia after major abdominal surgery. All 57 patients who underwent major abdominal surgery, admitted to a surgical ICU during a 6 months period beginning in January 2005. The following variables were recorded at admission: age, gender, ASA physical status, type of surgical procedure, history of smoking and Chronic Obstructive Pulmonary Disease (COPD). We also registered need of mechanical ventilation for more than 24 hours and the length of mechanical ventilation, as well as ICU and in hospital length of stay (LOS), mortality, Simplified Acute Physiology Score II (SAPS II). Assessment of the relation between each variable and the occurrence of postoperative pneumonia was made by univariate analysis performed by simple logistic regression with an odds ratio (OR) and its 95% confidence interval (95%CI). Outcome was compared between patients with pneumonia and patients that did not develop pneumonia. Eleven pneumonias occurred. Significant risk factors for the occurrence of pneumonia were mechanical ventilation for more than one day in the post operative period (OR 25, 95%CI 3-219, p=0.001), days on mechanical ventilation (OR 1.16, 95%CI 1.04-1.30, p<0.009 for each day), history of COPD (OR 8.5, 95%CI 1.9-38, p=0.05) and ICU LOS (OR 1.15, 95%CI 1.04-1.26, p<0.005 for each day in ICU). After major abdominal surgery the patients with previous history of COPD, patients that stayed more days on assisted ventilation in postoperative period and patients with longer ICU LOS should be considered in risk to develop pneumonia in post operative period

ICU Preventive maintenance of the development intraabdominal hypertension. Djura Sabirov, Uiugbek Batirov, Amin Saidov The Tashkent institute of postgraduate education for doctors, Tashkent, Uzbekistan. The Action directed on treatment intraabdominal hypertension (IAH) at postoperative period has their own particularities. However, presence to trends to his increasing requires conducting the preventive measures to correction. The Analysis was subject to 62 patients, handled on cause of the wide-spread peritonitis different reasons. 1 group with presence nasogastral probe (n=44), 2 groups patients with nasogastral by flexing + installed by epidural catheter for analgesia (n=18), All sick was conducted measurement intra-abdominal pressure (IAP)each 6 hours by classical method through urinary bladder during 5 day. The Analysis has shown that beside patient 1 groups average importance IAP greatly increased with 13, 60, 98 mm Hg before 19, 10, 94 mm Hg (r<0, 05) on 3 day of the study, with simultaneous increase HR 93, 2 4, 23 bpm and MAP 94, 4 3, 36 mm Hg and SVRI 1106, 2 51, 0 dynes. cm.-5. Beside sick 2 groups increasing IAP on 3 day after operation turned out to be small from 12, 3 1, 17 mm Hg before 15, 1 0, 84 mm Hg (r> 0, 05), under average hemodynamic factors HR 87, 0 3, 51 bpm, MAP 88, 3 3, 03 mm Hg and SVRI 971, 6 48, 13 dynes. cm.-5. One more important circumstance was time of the appearance of the active intestine peristalsis with output gases, beside patient 1 groups she has formed at the average 74, 7 4, 6? then beside patient 2 groups given factor had an all the difference in the world 46, 2 2, 8? (r<0, 05). Thereby, study has shown that using epidural analgesia at postoperative period in greater degree provides hemodynamic stability patient, moreover primary sympathetic blockade with improvement perfusion of organ to abdominal cavity provided the early activation of the intestine peristalsis and reductions IAP. After arrival on place

ICU Profile of germs resistance to antibiotics in a Tunisian ICU Frikha Nabil, Ouerghi Sonia, Trabelsi Chowki, Kraiem Aimen, zribi Najeh, Eddhif Mongi, Mebazaa Mhaled Sami, Ben Ammar Mohamed Salah. Anesthesiology, ICU and ED, Mongi Slim Hospital, La Marsa, Sidi Daoued, Tunisia.

The organisms isolated in the intensive care units from are more resistant to antibiotics than those insulated in the other care structures. Our study aim to determine the profile of germs resistance to antibiotics in a Tunisian medico-surgical intensive care. It is a prospective study, having included all patients having presented a nosocomial infection in the intensive care unit of the Mongi Slim hospital between April 2004 and May 2005. The patients have seen followed since the admission until the death or 48 hours after the exit. We raised the date of which has occurred of the infection, its site, germs and their resistance to antibiotics. 280 patients were included whose 73 patients (26%) had a nosocomial infection.The responsible germs are: Pseudomonas aeruginosa (24.7%), Staphylococcus aureus(13.9%), Escherichia coli (13.9%), Klebsiella (13.9%), Acinetobacter (8%), Proteus (6%), Enterobacter (5%), Serratia (2.5%), Staphylococcus coagulase negative (2.5%), enterococcus (2%) and others (yeasts, Providencia, pneumococcus...). We noted a strong proportion of multi resistant GNB to the antibiotics: Pseudomonas aeruginosa was resistant to Ceftazidine and imipenem in more than 50% of the cases, E coli and Klebsiella resistant to the third generation cephalosporines in 18% and 59% respectively. The GPC remain sensitive in the negative majority of the cases to antibiotics except the coagulase negative staphylococcus and enterococcus The great frequency of antibiotic prescription, the long stay of the patients in the structures of care and the emergence of resistant stumps to antibiotics in the general population explain the development of bacterial resistance to antibiotics in our intensive care unit.

ICU Prolonged exposure to inhaled nitric oxide transiently modifies tubular function in healthy piglets and promote tubular apoptosis Gozdzik Waldemar, Harbut Piotr, Zielinski Stanislaw, Ryniak Stanislaw, Dziegiel Piotr, Podchorska-Okolow Marzena, Kubler Andrzej, Frostell Claes. 1.3.7 Department of Anaesthesiology and Intensive Therapy, Medical University of Wroclaw, PL-40-368 Wroclaw, Poland 2.Karolinska Institutet, Department of Clinical Sciences, Division of Anaesthesia and Intensive Care, Danderyd University Hospital, SE18288 Stockholm, Sweden 4.8. Karolinska Institutet, Department of Physiology and Pharmacology, Division of Anaesthesia and Intensive Care, Karolinska University Hospital, Karolinska Institutet, SE-17176 Stockholm, Sweden 5.6. Department of Histology and Embryology Wroclaw Medical University PL-50-368 Wroclaw Poland Inhaled nitric oxide (iNO) is believed to be a selective pulmonary vasodilator. However some extrapulmonary, even renal effects of iNO have been reported. We have studied if prolonged exposure to 40 ppm iNO (30 hours) alters kidney function in healthy, intubated, spontaneously breathing piglets (PSV, PEEP 5 cm H20), weight 18 kg), in a blinded, placebo-controlled study. Animals (n=20) were randomized to receive 40 ppm iNO or placebo. Blood and urine samples were taken for 3 separate renal profiles of 12, 12 and 6 h. Samplings included: urine volume, plasma and urine electrolytes (UNa, UCl), creatinine, urea and creatinine- (Ccr), osmolality-, fractional excretions (FeNa, FeK), urinary excretions (UENa, UECl). Haemodynamic data included hourly measurements of heart rate, CVP and mean arterial pressure. We searched for signs of renal apoptosis with the TUNEL technique. Statistics: U-Test p<0.05 (*). For the first 12h profile (I), the following mean values (SD) were increased in the iNO vs. control group: UNa (mmol/l) 87, 7* (35, 0) vs. 39, 3 (22, 9), UCl (mmol/l) 80, 4* (32, 8) vs. 48, 0 (26, 7), FeNa (%) 2, 1* (0, 8) vs. 0, 7 (0, 5), without urine volume or serum creatinine changes. These modifications in renal profile were absent in period II-III. All haemodynamics remained stable with no differences between groups. A significant increase in percentage of apoptotic cell nuclei in tubule of renal cortex and medulla was found in iNO exposed animals. Prolonged exposure to 40 ppm iNO in healthy piglets transiently modifies kidney tubular function for the first 12h. Exposure to iNO can be seen as a stress to some cell populations in the kidney. Troncy 1997. Extra-pulmonary effects of inhaled nitric oxide in swine with and without phenylephrine. Br J Anaesth.79, 631-640. Lecour 2003. Evidence for the extrapulmonary localization of inhaled nitric oxide. Heart Dis 5, 372-377.

ICU Renal dysfunction after coronary arteries bypass grafting Yuri Morozov, Marina Charnaya, Vera Gladisheva, Natalia Savostianova Russian Research center for Surgery named by academician B.V. Petrovsky RAMS CPB is an essential risk factor of development postoperative transitory renal dysfunction (RD). Aim of idea: to study of tubuloglomerular disorders arising after CPB. Patients after coronary arteries bypass grafting undergoing CPB are surveyed: group 1 (n=45) - without infringement RD in the postoperative period, group 2 (n=35) - with development RD for 1 day after operation. Counted glomerular filtration rate (GFR) by Cockroft-Gault, concentration coefficient (CC) and fractional excretion Na+ (FENa) before operation, after CPB and for 1 day after operation Before operation all patients did not come to light infringements of renal function. After CPB at all patients decrease GFR more expressed in group 2 was registered. For 1 day after operation in group 1 GFR even exceeded reference values whereas in group 2 they remained lowered a little, and GFR at this stage was authentically less in comparison with preoperative values. After CPB in both groups increase FENa (?<0, 05) was marked, and in group 2 it was in 1, 7 times above, than in group 1. Thus groups authentically did not differ on plasmas and urine concentration Na+. For 1 day after operation FENa decreased in both groups, and in group 1 to values below initial, and in group 2 it exceeded initial values (p<0, 05). At this stage of group did not differ on concentration Na+ in plasma and urine. After CPB increase CC in both groups (p>0, 05) is noted. For 1 day in group 1 CC remained at postCPB values while in group 2 significant and its expressed reduction was registered. After CPB proximal renal tubules dysfunction is registered at all patients. The subsequent infringements distal renal tubules testify to preservation of ischemic damages renal tubules. The revealed infringements were realized in development transitory RD, not demanded carrying out of a hemodialysis.

ICU Sedation Score in Mechanically Ventilated Patients: Bispecteral Index Compared with Richmond Agitation- Sedation Scale Khadijeh Zeraatkar Darimi, Hassan Ali Soltani, Seyed Jalal Hashemi, Samire Shahin, Reihanak Talakoub, Bahram Soleymani Anaesthesia and Critical Care, Isfahan University of Medical Sciences, Isfahan, Iran The intensivist should be avoided over or under sedation in critically ill patients. There are controversies in order to validity of Bispecteral index (BIS) in the management of ICU patients (1, 2). The aim of this study was to evaluate sedation level in our surgical ICU (SICU) patients using BIS and Richmond agitation- sedation scale (RASS, as a valid tool) (3), and to determine the correlation between these two methods of evaluation. Following ethics committee approval, we determined the sedation level in 33 patients aged between 20-75 years who were mechanically ventilated and sedated routinely in SICU. In each patient we assessed BIS (zero to 100) values with simultaneously RASS (-5 to +4) twice a day at times two hours after receiving systemic sedation at morning and evening periods. Appropriate sedation score was considered -2 and -3 in RASS and 70 to 80 in BIS. Lesser or greater values considered as under or over sedation respectively. Data were analyzed using chi-square and spearmans correlation tests. The over, appropriate and under sedation frequency reported using BIS were 45, 35 and 121 times respectively. In 5 times which RASS detected over sedation, BIS also had the same results. RASS didnt detect any appropriate sedation at all. From the 1 96 times in which RASS detected under sedation, BIS distinguished 40 (20.4%) as over, 35 (17.9%) as appropriate and 121 (61.7%) as under sedation (p=0.000, r= 0.245). This study showed that most of our SICU patients were under sedate. BIS was poor correlated with RASS in assessing the depth of sedation in mechanically ventilated patients. 1. 2. 3. Mondello E. Minerva Anestesiol 2002, 68(1-2): 37-43. Mantz J. Ann Fr Anesth Reanim 2004, 23(5): 535-40. Sessler CN. Am J Respir Crit Care Med 2002, 166: 1338-1344.

ICU Sensitivity and Specifity of a new PCR-Based Assay for Rapid Pathogen Detection (SeptiFast) in Patients with Pancreaticoduodenectomy or Gastrectomy compared to standard blood culture Bingold Tobias, Scheller Bertram, Rnneberg Toni, Wilke Hans-Joachim, Wahrmann Mathis, Zwissler Bernhard, Wissing Heimo, Hunfeld Klaus-Peter. Clinic for Anaesthesiology, Intensive Care and Pain Therapy, J.W.Goethe-Universitiy, Frankfurt/Main, Germany Early specification of bacterial and fungal pathogens plays a crucial role in sepsis therapy. A new PCR system (SeptiFast, Roche Diagnostics) allows a more rapid identification of 25 of the most common pathogens compared to standard blood culture (BC). We sought to determine whether the PCR System also has a high sensitivity and high specificity after pancreaticoduodenectomy as compared to standard BC. After approval of the study by the local ethiccommittee and after having obtained informed consent, we included 22 Patients with gastric- or pancreatic cancer prior surgery. All Patients received ether a gastrectomy or a pancreaticoduodenectomy. Blood samples for PCR and BC were taken before surgery and at admission to the ICU and also afterwards up to 5 times, in a 24h period. Samples were taken by sterile venous puncture or from the arterial line. In total 94 paired blood samples were obtained from 22 patients. In 9 samples PCR were positive, and in 6 samples BC. In 5 positive BC`s the pathogen was considered contaminated. In 1 sample PCR and BC detected the same pathogens. This patient became septic 24 hours after surgery. PCR decteted enterobacter cloacae in a sample 24h before BC got positive on day two after surgery. In the samples PCR decteted enterococcus faecalis in 3 patients, in 1 patient enterococcus faecium, without signs of infection. In patients with severe sepsis detection of pathogens by PCR is more sensitive and timelier than by standard BC (1). The issue, whether after pancreaticoduodenectomy PCR will be false positive cannot jet be answered. We therefore conclude that real time PCR SeptiFast is more sensitive in detecting pathogens in sepsis than BC while being comparable in specificity to BC after abdominal surgery. 1. Bingold TM et al. 2007 Infection 35, Suppl II: 061

ICU Severe life-threatening hyponatraemia due to the use complementary medicine Ulf E. Kongsgaard, Elin Helseth, Siv Hestenes Dept. of Anaesthesia and Intensive Care, Rikshospitalet Radium Hospitalet, Oslo, Norway 20 % of Norwegian cancer patients use complementary and alternative medicine (CAM). Special diets and herbal medicines can cause severe side effects. We present a patient with severe hyponatraemia after such treatment. A 54 year old woman with advanced ovarian cancer was admitted to Humlegaarden Health Resort in Denmark where she received complementary cancer care consisting of Mistletoe extract (Iscador) injections, herbal tea, salt-deficient vegetarian diet, oral intake of pure water up to 5 l / day, vitamins and minerals, in addition to magnet fields, colour therapy and oxygen treatment. She was discharged from the Health Resort with a s-Na of 119 mmol/l. After 4 days at home with diarrhoea and deteriorating condition she was admitted to the Norwegian Radium Hospital. At admission: Weight 39 kg BW, HR 95, BP 80/50 mm Hg, poor peripheral circulation, no peripheral reflexes and clinical picture of slow cerebration. Lab. results: s-Na 102 mmol/l, s-K 3.3 mmol/l, s-Cl 67 mmol/l, s-osm 216 mosm/kg, u-Na 8 mmol/l, u-osm 231 mosm/kg. Treatment: I.v. isotone NaCl with a targeted correction of 0.5 mmol/hour first 24 hours, up to s-Na of 112 mmol/l, thereafter a correction of s-Na to 122 mmol/l during the next 2 days. Repeated MRI excluded development of central pontine myelinolysis. The patient was discharged without neurological sequelae. CAM sometimes use the appeal to nature fallacy, i.e. "that which is natural cannot be harmful". Anaesthesiologists treating cancer patients must be aware of potential lifethreatening side effects of CAM such as severe hyponatraemia, in our case, probably due to a combination of diuretic effect of herbal tea, water intoxication, salt-deficient diet, and diarrhoea that can be caused by large doses of vitamin C and vitamin E. Ang-Lee MK, Moss J, Yuan C-S. Herbal medicines and perioperative care. JAMA 2001, 286: 208-216

ICU Severe sepsis surveillance in Intensive Care Units in Poland Kubler Andrzej, Durek Grazyna Department of Anaesthesiology and Intensive Care The Medical University in Wroclaw Chalubinskiegostr. 1a 50-368 Wroclaw Poland Severe sepsis is the leading cause of death in intensive care units (ICUs) Different epidemiological studies are performed to assess the incidence, course and outcome of severe sepsis in ICUs. Simple, descriptive, observational studies are recommended for the longitudinal assessment of severe sepsis on different levels of health care systems (1) National system of severe sepsis surveillance in ICUs in Poland was introduced in April 2003.The participation in surveillance is voluntary.The questionnaire is completed after the end of severe sepsis treatment in ICU and sent to the designed website. 3984 cases of severe sepsis were registered from 140 ICUs till May 2007.Mean age was 54, 58% men. Intraabdominal and respiratory infections were common cause of severe sepsis. Mean admission Apache II was 24, mean daily SOFA 11 and TISS-24 37. The average ICU LOS was 17 days and mortality 52%. During last 3 years 16% decrease of relative mortality rate was observed. The system was very good accepted among the ICUs personal. The simple system of passive epidemiological surveillance used for registration of nosocomial infection proved to be useful for the longitudinal assessment of clinical syndrome. The continuous assessment of severe sepsis course in ICUs as well as treatment strategy was possible on the national level with this surveillance approach. ional level.. Martin G. (2006) Crit Care 10, 136

ICU Small volume acid aspiration induces pulmonary hypertension in rats Pawlik Michael T., Lubnow Matthias, Gruber Michael, Ittner Karl-Peter (1) Department of Anesthesiology, University Hospital Regensburg, Germany (2) Department of Cardiology, Pulmonology and Intensive Care Medicine, University Hospital Regensburg, Germany (3)Department of Anesthesiology, University Hospital Regensburg, Germany (4) Department of Anesthesiology, University Hospital Regensburg, Germany Acid aspiration is a serious complication during anesthesia, which may cause aspiration pneumonitis and adult respiratory distress syndrome.1 Endothelin is a vasoactive peptide that increases pressures in the pulmonary circulation and exhibits proinflammatory properties.2 Concurrent pulmonary hypertension could aggravate the initial course of the aspiration event, hence developing pulmonary hypertension is of clinical interest. The authors hypothesized that acid aspiration induces acute pulmonary hypertension even after small volume, and tested this hypothesis in a rat model. After obtaining approvement by the local animal ethic committee, male Sprague Dawley rats (n=24) anesthetized with sevoflurane underwent tracheostomy, and catheters were inserted into the carotid and right ventricle. The animals were ventilated for six hours and were randomized into two groups. Lung injury was induced by instillation of 0.4 ml/kg 0.1 N hydrochloric acid, a control group received the same amount of physiologic sodium chloride solution. Right ventricular systolic pressures (RVSP) were documented every thirty minutes, and drop out rate due to circulatory failure was documented. RVSP values were analyzed by mixed linear models for unbalanced and dependent data, survival rate by Kaplan-Meier analysis. Right ventricular systolic pressures showed a significant group- and time-dependent effect over the entire course of the experiment, comparison of corresponding time points from t 90 showed significant differences of the mean. Mortality rate was 50% after HCl aspiration, while 100% of rats survived NaCl aspiration. Small volume acid aspiration induces a significant increase in right ventricular systolic pressure and results in a higher mortality in this animal model. 1. 2. Warner MA, Warner ME, Weber JG: Clinical significance of pulmonary aspiration during the perioperative period. Anesthesiology 1993, 78: 56-62 Michael JR, Markewitz BA: Endothelins and the lung. Am J Respir Crit Care Med 1996, 154: 555-81

The study was financally supported exclusively by the department of anesthesiology.

ICU The effect of Acetyl-L-carnitine on LPS-induced TNF productionin in post-hypoxic condition. Masanori Ogata M.D. Hitomi Tamura M.D. Takeyoshi Sata M.D Dept. of Anesthesia, Univ. of Occup.&Environ. Health, Kitakyusyu, Japan Acetyl-L-carnitine (ALC) is an ester of L-carnitine. Acetyl-L-carnitine facilitates the uptake of acetyl CoA into the mitochondria during fatty acid oxidation, enhances acetylcholine production, and stimulates protein and membrane phospholipids synthesis. Studies have shown that ALC may be of benefit in treating Alzheimers dementia, diabetic neuropathies, ischemia and reperfusion of the brain, and cognitive impairment of alcoholism. The aim of the study is to investigate the effect of ALC treatment on LPS-induced TNF production in post-hypoxic condition of mouse macropharge cell line. Cell Culture: RAW264.7 cells (1X105 cells/ml) was seeded in 24-well plates and grown to confluence. After exchange fresh medium RPMI 1640 with 10% fetal calf serum, plates were cultured in a humidified incubator with 5% CO2 and 95% air (Normal) condition or 5% CO2 and 0.1% O2(Hypoxic) condition. After 12 hr incubation, each plate was washed twice by PBS and exchanged the fresh medium. After 30 min treatment with various doses of ALC, cells in each plate were stimulated LPS and incubated for 24hrs with 5% CO2 and 95% air. Supernatants were collected and production of TNF was measured by ELISA. Statistics: Sequential changes in all variables were compared with controls using the repeated measurements of ANOVA. Bonferronis correction was applied for multiple comparisons. Differences were considered significant at probability values of less than 0.05. LPS induced TNF production was enhanced by hypoxic state culture in comparison with normal culture. In normal incubation, ALC 5mM treatment significantly inhibited the LPS induced TNF production. In both condition, ALC 5mM treatment significantly suppressed LPS-induced TNF production(P<0.05). Hypoxic condition increase LPS induced TNF production. ALC treatment may inhibit inflammatory cytokine in post-hypoxic condition.

ICU The Effect of Propofol and Midazolam to the Translocation of NF-kappaB in the LPS-induced Monocytes Ying Fan, yonghao Yu, guolin Wang Tianjin Medical University General Hospital, Tianjin, China Our goal is to study the effects of propofol and midazolam on the translocation of NF-?B in monocytes and discussion the possible machenism and whether this can be influenced by flumazenil . PBMCs were isolated and cultured . After flumazenil preconditioning , different concentrations of propofol(1 , 10, 50 microg/ml, ) and midazolam( 1 , 10microg/ml)were added respectively , then LPS 1 microg/ml .Nuclear factor-kappaB activation and translocation of p65 subunit of NF-kappaB was measured using immunocytochemistry. Without flumazenil preconditioning , propofol and midazolam with low concentration has no effect on the translocation of NF-?B, while the translocation of NF-?B in LPS-induced monocytes can be inhibited significangly(p<0.01)in higher concentrations. When flumazenil was added , the inhibition of NF-?B by propofol and midazolam can be alleviated . This study demonstrated propofol and midazolam can inhibited the translocation of NF-?B in LPS-stimulated monocytes in a dose dependent manner , while flumazenil preconditioning can alleviate this effect by binding to the benzodiazepine receptors . 1.Hoffmann A, et al. Genetic analysis of NF-kB/Rel transcription factors defines functional specificities.EMBO J, 2003, (22):5530-5539. 2.Hoffmann A, et al. The IkB-NF-kB signaling module: temporal control and selective gene activation.Science, 2002, (298):1241-1245. 3.Gao J , Zhao WX , Zhou LJ, et al. Protective effects of propofol on lipopolysaccharide-activated endothelial cell barrier dysfunction.Inflamm Res, 2006 , 55(9):385-92. 4.Masahiro Irifune, Tohru Takarada, Yoshitaka Shimizu, et al.PropofolInduced Anesthesia in Mice Is Mediated by ?-Aminobutyric Acid-A and Excitatory Amino Acid Receptors. Anesth Analg, 2003, 97:424-429. 5.Seon Nyo Kim, Soo chang Son, Sang Mook Lee , et al .Midazolam inhibits proinflammatory mediators in the lipopolysaccharideactivated macrophage.Anesthesiology, 2006, 105:105-110. Id like to appreciate to all the professors in Tianjin Medical University General Hospital.

ICU The effects of hyperbaric oxygen treatment after experimental carbonmonoxide poisining on antioxidant enzyme and malonyldialdehyde levels Gner Dagli, Nurten Guducu, Kamer Genc, Ertan Teksoz, Huseyin Sen, Sezai Ozkan GATA Haydarpasa Training Hospital, Department of Anesthesiology and Reanimation In our study we investigated the effects of HBO treatment after acute CO poisinig on levels of SOD, GSH, GSH-PX, catalase and MDA in brain tissue. We performed the study in GATA Haydarpasa Training Hospital, Sea and Underwater Medicine Department Labrotories. We used 30, 33-36 weeks old, 250-300 gr mature, healty, Sprague-Dawleys rats. In an airtight chamber the rats were exposed to CO of 10000 ppm concentration for two minutes. Rats were randomly allocated into three groups. Group 1 (n=10) was given no treatment (room air). Group 2 (n=10) was treated with %100 O2 at 2 ATA for 90 minutes. Group 3 (n=10) was treated with %100 normobaric O2 at for 90 minutes. After treatment protocols in the GATA Haydarpasa Training Hospital Clinical Biochemistry labaroties the brain tissues of all rats were extracted and the level of SOD, GSH-PX, catalase and MDA were measured in a supernatant form of the tissues. In group 2 the levels of antioxidant enzyme were high and levels of MDA showing the level of oxidative stress were low. In conclusion, we biochemically proved the efficacy of HBO treatment in preventing the early and late sequela of CO poisining. But further investigations is needed to understand the relationships between antioxidant enzymes. Further investigation is reguired to clarify how HBO2 treatment increases antioxidant enyzmes.

ICU The Effects Of Hyperbaric Oxygen Treatment And Timing On Gram Negative Sepsis Induced Rats Sezai Ozkan, Ersel Budak, Ertan Teksz, Kamer Dere, Hseyin Sen, Gner Dagli GATA Haydarpasa Training Hospital, Department of Anesthesiology and Reanimation HBO treatment is used in the treatment of a very large scale of disturbances and its effectivity in sepsis is shown in several animal studies.In this study our aim is to examine the efficacy of timing in a well studied pressure level in the base of cytokine and biochemical changes those involved in sepsis. In our study we divided 40 male adult Wistar rats into five groups. In group 1, 1 ml of 0, 9% salin solution was injected intraperitoneally. And in group 5, 1 ml of 0, 5 Mc Farland E. coli (ATCC 25992) solution was injected intraperitoneally. In groups 2, 3 and 5, 1 ml of 0, 5 Mc Farland E. coli (ATCC 25992) solutions were injected intraperitoneally and the rats were treated with HBO at 2, 5 ATA with 6 hour intervals after the 2, 6 and 12 hours of injection, respectively. At the end of treatment the livers, kidneys, brains and blood of the rats were harvested. In serum, interleukin 1-beta(IL-1 beta), tumor necrosis factor (TNF), interleukin 10 (IL-10) and nitric oksit products (NOx) levels, in tissues glutathion peroksidase (GP), superoksit dismutase (SOD), catalase (CAT) and lipid hydroperoxide levels (LPO) were studied. We found increases in the IL-10, GP, SOD and CAT levels and decreases in the IL-1, TNF, NOx and LPO levels after HBO treatment. The effects of treatment were mostly observed in Group II (p<0.05). We concluded that the HBO treatment is effective in the gram Negative Sepsis and this effect is associated with the timing of the therapy. However these results need to be supported with further studies. 1. 2. Benedetti S., Lamorgese A. Clin. Biochem. 37: 312317, 2004. Bitterman H., Muth C.M. Intensive Care Med. 30:10111013, 2004.

ICU The effects of recruitment maneuvers on dead space in ali/ards patients Ayla Esin, Yalim Dikmen, Oktay Demirkiran, Tughan Utku, Seval Urkmez ISTANBUL UNIVERSITY CERRAHPASA MEDICAL SCHOOL In previous studies Recruitment Maneuvers and its effect on dead space hasnt been studied. We aimed to evaluate the effects of recruitment maneuver and decremental PEEP titration on increased dead space in ALI/ARDS patients. Twelve patients who suffered ALI/ARDS were included in the study. Meeting ARDS criteria patients were ventilated with protective ventilation strategy. Lung mechanics (Cdyn, Ppeak, Pmean, EtCO2) and dead space were measured using "single breath test", then recruitment maneuver and PEEP titration were applied to maintain "Optimal PEEP", after that recruitment maneuver and lung mechanics measurements were repeated. Patients hemodynamics (SABP, DABP, HR) also were recorded. Physiological and anatomical dead space were significantly decreased (respectively p=0, 028, p=0, 08). PO2 and oxygen saturation were significantly increased (respectively p=0.01, p=0.02), pH values were significantly decreased (p= 0.06). Changes in alveolar dead space, EtCO2 , Cdyn, Ppeak, Pmean, SABP, DABP, HR and PEEP were not significantly different. In previous studies dead space fraction in early phase of ARDS is statistically significantly elevated in nonsurvivors and associated with an increased risk of death (1) and VD/VT was markedly elevated within 24 hours of the onset of ARDS in dead ones (2), therefore measurements in the first day of ARDS may have prognostic value . In conclusion protective ventilation with recruitment maneuver and Optimal PEEP could reduce physiologic dead space in early stage of ARDS. 1. 2. Nuckton TJ, Alonso JA, Kallet RH, Daniel BM, Pittet JF, Eisner MD, Matthay MA. Pulmonary dead-space fraction as a risk factor for death in the acute respiratory distress syndrome. N Engl J Med 2002,346:1281-6. Kallet RH, Alonso JA, Pittet JF, Matthay MA. Prognostic value of the pulmonary dead space fraction during the first 6 days of acute respiratory distress syndrome. Respir Care 2004,49(9):1008-1014

ICU The Prognostic Value of Atrial and Brain Natriuretic Peptide, Troponin I and CRP in Patients With Sepsis Tuba Yucel, Dilek Memis, Beyhan Karamanlioglu Trakya University Medical Faculty, Department of Anaesthesiology, Edirne, TURKEY Our objective was to investigate the plasma levels of atrial and brain natriuretic peptides, troponin I, C- reactive protein (ANP, BNP, cTnI, CRP, respectively) and the prognostic value of these markers in patients with sepsis. This is a prospective study of 40 patients over 18 years old with sepsis at the intensive care unit in Trakya University Medical Faculty, Turkey. The patients were divided into two groups containing 20 patients as survivors (Group I) and non-survivors (Group II). The blood collection was performed on the day of diagnosis, 2nd day and the day of discarge or death. Statistically significant low ANP and low BNP values were determined in Group I compared with Group II on the day of diagnosis, 2nd day and the day of discarge or death (p=0, 001, p<0, 001, p<0, 001)(p<0, 005) respectively. Statistically significant low CRP values were determined in Group I compared with Group II on the 2nd and last day. Statistically significant low cTnI values were determined in Group I compared with Group II on the 2nd and last day. According to the results of our study, at the day of diagnosis and 2nd day the strongest test on predictimg the prognosis was BNP (p<0, 001). ANP, APACHE II, CRP and cTnI were following BNP respectively. At the last day the strongest values on predicting the prognosis were BNP(p<0, 001) and APACHE II(p<0, 001). Last day ANP, CRP and cTnI were following BNP and APACHE II respectively. We conclude that ANP, BNP and APACHE II values reflects(projects) the prognosis in septic patients, and also with initial cTnI and CRP values, it is impossible to predict the prognosis but during the follow-up these values can demonstrate the status of prognosis. There are several factors affecting those five parameters thereby we suppose that further research should be performed.

ICU The use of norepinephrine to increase blood pressure during endotoxemia is associated with increased intracranial pressure but not regional cerebral blood flow. Baenziger Bertram, Regueira Toms, Brandt Sebastian, Gorrasi Jos, Oevermann Anna, Mettler Daniel, Djafarzadeh Siamak, Jakob Stephan. Departments of Anesthesiology, Intensive Care Medicine, and Clinical Research, University and University Hospital Bern, Bern, Switzerland In sepsis, brain dysfunction is common (1). While low blood pressure is usually treated, blood pressure targets are controversial. The aim of this study was to evaluate the effect of norepinephrine to increase systemic arterial blood pressure (MAP) on cerebral hemodynamics, tissue oxygenation and histopathological signs of inflammation during early endotoxemia. E. coli lipopolysaccharide was infused in 12 anesthetized pigs randomized to norepinephrine (NE) or placebo infusion (P) for 10 hours. NE dose was adjusted two-hourly to achieve increasing mean arterial blood pressure (MAP) up to 95 mm Hg. Systemic (CO, thermodilution) and carotid (CA, ultrasound Doppler) blood flow, intracranial pressure (ICP), jugular venous oxygen saturation (SjvO2) and brain tissue pO2 (pbrO2) were measured serially. At the end of the experiment, formalin fixed brains were cut in coronal sections, embedded in paraffin and later cut at 5 microns and stained with HE. After 10 hours, MAP was 91 12 in NE and 64 3 in P (p<0.05). CO increased more in NE (from 109 20 to 212 70 ml/kg/min vs. from 96 13 to 136 47 ml/kg/min, p<0.03 between groups). ICP increased only in NE (from 9 3 to 18 5 mmHg, p<0.001). CA, SjvO2 and pbrO2 did not change in either group. In all animals from both groups, signs of global cerebral edema, and also in 10/12 animals (NE: 5/6, P: 5/6) signs of endothelial inflammation, were present in the brainstem, midbrain, thalamus, basal nuclei and cortex. The use of norepinephrine was associated with an increase in CO, MAP and ICP but not CA. This did not affect cerebral oxygenation or the extent of brain swelling and vascular inflammation. 1. Bleck TP, Smith MC, Pierre-Louis SJ, et al. Crit Care Med 1993,21:98-103.

ICU The use of pancuronium as adjuvent beyond antitetanic serotherapy intrathecal Isokuma Bula - Bula, Manzanzakilembe, Mohobo Ekutsu (1) Hpital de Ndjili, Institut suprieur des techniques mdicales / Kinshasa / Rep. Dm. Congo (2) Dpartement dAnesthsie, Cliniques Universitaires de Kinshasa, Universit de Kinshasa Tetanus is a several disease. The antitetanus serum, used in curative treatment, does not have any effect on the toxin already fixed. Several studies improve that the administration intrathecal curare causes a myorelaxation(1, 2). Moreover, these molecules can interfer with the toxins fixing. In order to evaluate the effect of a concommittente intrathecal administration of a curare, in occurrence the pancuronium, with the SAT, an exploratory study has been done at Ndjili hospital. This study related to all the patients admitted for tetanus generalized to the aforesaid hospital. The enlightened assent was obtained for all the patients. these patients received by intrathecal way, a mixture of pancuronium (0.033mg/Kg) with of bovin SAT(100 UI/Kg). An additional amount of SAT was given by subcutaneous way. Those patients profited from other mesures necessary to the assumption of responsibility of tetanus : Debridement and the cleaning with hydrogen peroxide, sedation, antitetanus vaccination and the administration of antibiotics. The monitoring was clinical. 12 patients were allowed to the study. Their average age was of 30.70 + 17.65 years. The entry door was cutaneous for 11 patients and post-operative for the twelveth. A reduction of contractions has been noticed. The average duration of these contractions was of 5 + 2.69 days. No contraction had been observed beyond ten days. A patient (8%) died in the 24 hours after his admission. It comes out from this study that the use of Pancuronium as auxiliary intrathecal of the SAT improves the forecast of tetanus. 1. 2. Szenohradszky J., Trevor AJ.and coll., Central nervous system effects of intrathecal muscle relaxants in rats, Anesth Analg, 1993 Jun, 76 (6):1304-9 Peduto V.A, Gungui P. and coll., Accidental subarachnoid injection of pancuronium, Anesth.Analg., 1989, vol.69, n4, pp.516-517

Tetanous - pancuronium intrathecal

ICU Therapeutic Hypothermia after Cardiac Arrest Hans Kirkegaard, Louise Pape, Klaus Christensen Department of Anaesthesia and Intensive Care, Aarhus University Hospital, Skejby, Denmark. Therapeutic hypothermia (TH) is recommended for treating out of hospital cardiac arrest due to ventricular fibrillation (VF)(1). The aim of the present study was to investigate the association between cerebral outcome and 1) Time from collapse to start of TH, 2) Time from start of TH to obtaining target temperature and 3) arousal time following end of treatment in patients treated with TH after cardiac arrest. From October 2004 to December 2006, 55 patients (age 63 (56-70) years, median (25-75 % percentile)) were treated with TH at Aarhus University Hospital, Skejby. All patients suffered from out-of-hospital cardiac arrest, 46 had VF and 9 asystole. The target temperature, 32 34 degrees centigrade, was maintained for 24 hours. Cerebral Performance Category Sore (CPC) was used to evaluate cerebral performance. Good outcome was defined as CPC score 1-2, bad outcome as CPC score 3-5. There was no significant association between cerebral outcome at discharge from hospital and time from collapse to start of TH (90 (43-156) min) or time from start of TH to obtaining target temperature (247 (175-342) min). There was a significant association between arousal time and cerebral outcome. In patients awake within 2 days, 86% were discharged with god cerebral outcome. In those awake after 3 to 6 days the figure was 50%. Patients not awake after 6 days all died that means 0 % with a good outcome. In this last group time to return of spontaneous circulation after collapse was significantly longer, compared to the other two groups. Within the time limits studied, time from collapse to initiation of TH and time from initiation of TH to target temperature has little influence on cerebral outcome. Time from attainment of normal temperature to arousal is of great significance to survival. Resuscitation 2003, 57: 231-5.

ICU Timing of tracheostomy as determinant of during of mechanical ventilation in critically ill patients: a retrospective study. Mehrdad Masoudifar Mehrdad Masoudifar M.D. Assistant professor of anesthesiology. Isfahan University of medical sciences. Email:dr22m@yahoo.com Address: post box: 576-Department of anesthesia- Alzahra hospital Isfahan- Iran to investigated the timing of tracheostomy and other factors that might influence duration of mechanical ventilation: Over a period of 24 months (from July 2004 to July 2006) all adult patients admitted to the medical ICU of Al-Zahra hospital (a 2000-bed tertiary medical centre) in Esfahan- Iran considered for inclusion in the study. Data of underlying disease, causes of respiratory failure, age, sex, duration of mechanical ventilation and interval of tracheostomy from intubation time were collected. Timing of tracheostomy and weaning base on sex were analyzed using T-Test. The correlations between the timing of tracheostomy and ventilation period, and between intubation period and ventilation period with age were analyzed using a Pearson bivariate correlation test. P < 0/05 was statistically significant. A total of 100 patients, %66 were men and mean of age 56/2 + 20/8 years included in the study. The timing of tracheostomy didnt exhibited a correlation with length of mechanical ventilation (r=0/08, P = 0/43) .The timing of tracheostomy and length of mechanical ventilation hadnt correlation with age of patients (r=0/129 , P=0/20 and r=0/02, P=0/83). The timing of tracheostomy and mechanical ventilation period hadnt significant different base on sex. (P= 0/5 and P=0/89). In this study we found that in patients with good pulmonary function, the timing of tracheostomy hasnt influence the duration of mechanical ventilation Reference: 1. Esteban A, Anzueto A, Alia I, Gordo F, Apezteguia C, Palizas F, Cide D, Goldwaser R, Soto L, Bugedo G, et al.: How is mechanical ventilation employed in the intensive care unit? An international utilization review.Am J Respir Crit Care Med 2000, 161:1450-1458. Heffner JE, Miller KS, Sahn SA: Tracheostomy in the intensive care unit. Part 1: Indications, technique, management.Chest 1986, 90:269-274. Heffner JE: Medical indications for tracheotomy.Chest 1989, 96:186-190

2. 3.

ICU Training in heart-lung-resuscitation is it necessary? Enlund Mats, Sdersved-Kllestedt Marie-Louise, Leppert Jerzy Centre for Clinical Research , Central Hospital, Vsters, Sweden Repetitive learning and training in heart-lung-resuscitation (HLR) is highly recommended world wide, and is by some regarded as a quality indicator of hospital care (1). At our hospital, no organisation has been in function for HLR training of ward staff, only anaesthesia and emergency staff has been trained regularly. We therefore assumed that the survival rate after heart stop at our hospital would be low, < 20%, compared with other hospitals in Sweden. We joined the National Register for Heart Stop in May 1, 2006. All protocols from HLR were registered. Daily check-ups with the hospital switch-board were undertaken in order to check that all alarms were noted in protocols and sent to a co-ordinator (M-L S-K). Register data for the first 12 months were analysed for mortality and live discharge and compared with recent outcome in Sweden. Of 92 registered alarms during the study period 15 were excluded for further analysis due to non-cardiac causes, and data from three heart stops were lost. The mortality rate of the remaining 74 patients was 69%. The 23 survivors (31%) were apparently younger than the non-survivors, mean 66.8 vs 76.9 years of age, respectively. The national best results are from Gothenburg with a survival rate of 37%, while the national average was 28%. The survival rate in terms of live discharge from hospital was better than expected. An explanation might be that patients with obvious poor prognosis were excluded from start, i.e. no alarm was elicited. Despite the unexpected positive outcome, mortality is still high for heart stop patients with an indication for repetitive training. 1. European Resuscitation Council guidelines for resuscitation 2005. Resuscitation, 2005,67:Suppl 1.

The County Council of Vstmanland and the University of Uppsala.

ICU Using Clinical Decision Support to Improve the Care of Patients with Sepsis Karen Giuliano, Erica Cummings, LuAnn Staul, Michele LeCardo 1, 2 Philips Medical Systems, Andover, MA 3 Legacy Health, Portland, OR 4.St Vincents Hospital, Bridgeport, CT Evidence suggests that early, aggressive resuscitation for patients with septic shock can have a significant impact on morbidity and mortality. Even with the widespread awareness of the Surviving Sepsis Campaign (SSC) guidelines, adherence varies widely. Clinical decision support systems can help clinicians improve various aspects of clinical practice, particularly when they are integrated into clinical practice and present at the point of care. Protocol Watch (PW) was developed as a bedside tool to assist clinicians with both implementation of and compliance with the SSC guidelines. The purpose of this research was to measure the impact that using PW had to adherence to the SSC guidelines. Participants were critically ill patients in two large university-affiliated teaching hospital intensive care units in the United States. Prior to the installation of PW, implementation of the SSC was done using a paper-based system of standing orders. Base line data on compliance with the SSC guidelines were collected. Protocol Watch, which offers an electronic version of the guidelines and is resident on the bedside patient monitor, was then installed in all critical care beds. The post PW installation data collection is currently being collected. Preliminary results show an improvement in compliance with both the resuscitation and management bundles. In Group 1, resuscitation bundle completion was 56% as compared to 83.3% in Group 2. . In Group 1, management bundle completion was 75% as compared to 87.5% in Group 2. In addition, the feedback from the clinical users has been extremely positive. If the final data analysis supports the preliminary findings, PW could emerge as an important method for assisting in the implementation of the SSC guidelines, thus making a valuable contribution in the care of critically ill patients with sepsis.

ICU Ventilator associated pneumonia: Incidence and predictive factors Ourghi Sonia, Frikha Nabil, Trabelsi Chowki, Samer Salim, Zribi Najeh, Kraiem Aymen, Mebazaa Mhamed Sami, Ben Ammar Mohamed Salah. Anesthesiology, ICU and ED, Mongi Slim Hospital, La Marsa, Sidi Daoued, Tunisia. The infections acquired under mechanical ventilation remain the most frequent nosocomial infections. An effective prevention passes obligatorily by a good knowledge of the factors of risk. In this study, we tried to identify some of the predictive factors occurred of respiratory nosocomial infections. Prospective study having included all patients having presented a nosocomial infection in the intensive care unit of the hospital Mongi Slim. The patients have seen followed since the admission until the death or 48 hours after the exit. We raised the reason of admission, the origin of the patient, the scores of gravity, the duration of stay in ICU, the duration of mechanical ventilation and the type of nosocomial infection. 74 episodes of nosocomial infections were listed either 0, 53/1000 patient/day including 33, 9% of respiratory infections, 27, 4% of urinary infections and 11, 3 % of infection of the operational site. Total mortality was 43%, against 63% among patients having presented a nosocomial infection (P < 00.1). The duration of mechanical ventilation is of 5 +/- 7 days against 14+/- 13 days among patients having presented at least an episode of lung nosocomial infection. The age, the sex and the score SOFA do not seem to be predictive factors of occurred a ventilator associated pneumonia. Only the duration of mechanical ventilation seems to be in our study a predictive factor of which has occurred of respiratory nosocomial infections

Ventilator-Associated pneumonia, emergence of high rates of bacterial resistance Huda, Nasser Aleppo University, Faculty of Medicine, Department of Anaesthesia & ICU Departement of Internal Medicine, Pulmonary division. Faculty of Pharmacy, Department of Microbiology. Ventilator- associated pneumonia (VAP) is one of the most common infections acquired among patients admitted to ICU and required mechanical ventilation. We conducted this study to clear the prevalence of local pathogens and their antibiotics resistance & susceptibility. During one year time, we studied all patients admitted to our ICU and required mechanical ventilation . we suspected VAP when CPIS>6 , to confirm diagnosis we took samplesguided by fibreoptic (BAL) , or quantitative endo-tracheal aspirate.& studied the isolated pathogens in early & late VAP , antibiotics sensitivity , resistance , and mortality rate. 648 patients were admitted, 318 of them required mechanical ventilation, 216 patients (67.9%) developed VAP, early VAP (52.3%), late (47.7%). the specific pathogens of 45 patients bronchoscopically- guided specimen (BAL) were : Acinetobacter 10% , ps. Aeruginosa 16% , Enterobacter 37% , staph. 19% ( 63% of them MRSA). Individual isolates were studied, incidence of antimicrobial resistance was very high, especially for protus , ps.aer. staph .epedermidus. Mortality rate was 45% for all admission , 72% for all VAP patients,68% for diagnosed VAP by BAL , 85% in MRSA diagnosed. The significant high infection and mortality rate with high antimicrobial resistance , related strongly to the misuse of antibiotics in our practise , and inappropriate hygienic technique. All of these lead to emergence of very high bacterial resistance to all known antibiotics. This research done in department of anaesthesia & ICU in cooperation with department of internal medicine pulmonary division, and microbiology department in faculty of pharmacy. Financially supported by Aleppo university.