Cutoff value 17 57.5 0.93 Sensitivity 64 71.6 73.6 Specificity 62.4 57.4 57.6 Positive predictive value 41.95 41.41 41.84 Negative predictive value 80.33 82.78 84.04
S159 P391
Raised C-reactive protein on ICU discharge is not associated with subsequent poor outcome
TE Reynolds, N Al-Subaie, A Myers, M Saidi, R Sunderland, A Rhodes, RM Grounds
St George’s Hospital, London, UK
Critical Care2009, 13(Suppl 1):P391 (doi: 10.1186/cc7555) Introduction It has been suggested that plasma C-reactive protein (CRP) levels measured on discharge from the ICU may be a useful predictor of either unplanned readmission or unexpected death on the ward. Previous work has found that raised plasma CRP independently predicted, in separate studies, each of these two poor outcomes [1,2]. We investigated whether these results could be repeated in our mixed medical/surgical ICU for a composite poor outcome measure combining death and readmission. Methods We prospectively enrolled a cohort comprised of all ICU admissions over 1 year. We collected admission clinical and demographic data and APACHE II scores. At discharge we recorded the white cell count and serum levels of CRP and albumin, and we observed death and readmission outcomes up to 2 weeks after ICU discharge. This time period was chosen on the grounds that an association between discharge CRP and postdischarge outcome should relate to persisting inflammatory activity and would be of most relevance in the short term.
Results Of 1,487 admissions to our ICU, 181 (12.2%) resulted in the patient’s death on the ICU and 110 (7.4%) ended with either the patient’s discharge to another hospital or ICU and thus their loss to follow up. Eleven patients discharged for palliation were excluded from analysis. A total of 1,185 (79.7%) were discharged to a ward in the hospital and so could potentially have suffered an unexpected deterioration resulting in ICU readmission or death. Of these, 117 (9.9%) of the discharge episodes were followed by an unexpected poor outcome of either readmission (n = 83, 7.0%) or
death (n =34, 2.9%) within 2 weeks. A composite outcome measure combining these two poor outcomes was associated with age, higher APACHE II score, and a low plasma albumin on ICU discharge. Means and median values were compared using
P<0.05 as the test of significance. Plasma CRP on discharge from the ICU was not associated with this composite measure.
Conclusions In a mixed medical/surgical ICU, CRP on the day of discharge is not associated with a poor outcome measure of unexpected readmission or ward death.
References
1. Ho KM, et al.: C-reactive protein concentration as a predic- tor of in-hospital mortality after ICU discharge: a prospec- tive cohort study.Intensive Care Med2008, 34:481-487. 2. Kaben A, et al.: Readmission to a surgical intensive care
unit: incidence, outcome and risk factors.Crit Care2008, 12:R123.
P392
Influence of age on the distribution of morphine and morphine-3-glucuronide across the blood–brain barrier in sheep
P Ederoth1, J Bengtsson2, D Ley1, S Hansson1, I Amer-Wåhlin1,
L Hellström-Westas1, K Marsal1, M Hammalund-Udenaes2,
CH Nordström1
1University Hospital, Lund, Sweden; 2Uppsala University, Uppsala, Sweden
Critical Care2009, 13(Suppl 1):P392 (doi: 10.1186/cc7556) Introduction Neonates are recommended smaller doses of morphine than adults and, accordingly, we hypothesised that the distribution of morphine and its metabolites over the blood–brain barrier differs between these age groups. In addition, neonatal asphyxia, with potentially harmful effects on the brain, in theory, might further affect the pharmacokinetics of substances over the blood–brain barrier.
Methods During anaesthesia, microdialysis probes were inserted into the brain cortex and in a central vein of 11 exteriorized near- term lambs (127 gestation days) and six nonpregnant adult sheep. Five of these lambs were subjected to 10 minutes of asphyxia through umbilical cord occlusion during delivery. Morphine, 1 mg/kg, was thereafter intravenously administered as a 10 minute constant infusion. Microdialysis and blood samples were collected for up to 360 minutes after morphine administration, and analyzed using liquid chromatography followed by tandem mass spectrometry. Data presented as the mean ± SD.
Results The morphine unbound drug brain:blood distribution ratio (Kp,uu) was 1.19 ± 0.20 and 1.89 ± 0.51 for the sheep and premature lambs without asphyxia, respectively (P = 0.018). The half-lives in the blood and brain cortex, clearance, volume of distribution, and distribution in the brain of unbound drug were all numerically significantly higher in the adult sheep as compared with the premature lambs. The morphine-3-glucuronide Kp,uuvalues were 0.27 ± 0.16 and 0.17 ± 0.15 in sheep and premature lambs (P = NS), indicating a net efflux from the brain in both groups. Induced asphyxia did not affect the results.
Conclusions The morphine Kp,uuwas above unity, indicating a net influx of morphine into the brain. In addition, influx was significantly higher in premature lambs than in adult sheep. We interpret this as an active transport of morphine into the brain, which may be counteracted with increased efflux with age. Further, neonatal asphyxia did not change these pharmacokinetic findings. The Kp,uu
in the sheep was different from the values obtained in humans (0.64), rats (0.49), mice (0.5) and pigs (0.47), where a net efflux of morphine from the brain was observed.
S160 P393
Epidural anesthesia during surgery: friend or foe? E Koepfli, S Brandt, O Kimberger, L Hiltebrand
University Hospital Bern, Switzerland
Critical Care2009, 13(Suppl 1):P393 (doi: 10.1186/cc7557) Introduction Decreased intestinal microcirculatory blood flow (MBF) is an important contributor to perioperative morbidity. Epidural anesthesia (EA) may improve intestinal MBF [1] but other researchers found that EA decreases cardiac output (CO) and thus compromises intestinal MBF [2]. We tested whether EA plus intravenous colloids result in increased intestinal MBF compared with colloid administration alone.
Methods Twenty pigs (30 ± 2.5 kg) were anesthetized and venti- lated. A laparotomy was performed for instrumentation and a colon anastomosis. After baseline measurements the animals were randomly assigned to one of the following treatments: Group HES, hydroxyethyl starch (130/0.4) was given to maintain SvO2≥60%; Group EA, in addition to the same colloid treatment an epidural catheter was inserted at the lumbar level and after a bolus of 4 ml ropivacain 0.2%, 7 ml/hour were continuously administered. The CO and MBF in the mucosa of the jejunum, colon and anastomosis were measured. Results In both groups the CO and MBF increased similarly (Table 1). No difference in the circulatory parameters between the two groups was found. However, in Group EA significantly more fluids (56%) were administered to achieve SvO2≥60%.
Table 1 (abstract P393)
Comparison of the treatment groups
Group HES Group EA HES (ml) 831 ± 94 1296 ± 81* Mean arterial pressure (%) 130 ± 3 124 ± 6 CO (%) 143 ± 7 143 ± 6 MBF jejunum 145 ± 8 107 ± 8 MBF colon 133 ± 6 130 ± 3 MBF anastomosis 166 ± 27 150 ± 17 Data presented as percentage ± SEM of baseline unless otherwise stated. *P <0.01 compared with group CO.
Conclusions The present study did not show any positive effects of epidural anesthesia on intestinal microcirculatory blood flow. On the contrary, over 50% more fluids were needed to maintain similar perfusion parameters than with fluids alone. Such a fluid load as needed in the epidural group may potentially be harmful.
References
1. Sielenkämper AW, et al.: Thoracic epidural anesthesia increases mucosal perfusion in ileum of rats.Anesthesiol- ogy2000, 93:844-851.
2. Schwarte LA, et al.: Effects of thoracic epidural anaesthesia on microvascular gastric mucosal oxygenation in physio- logical and compromised circulatory conditions in dogs. Br J Anaesth2004, 93:552-559.
P394
Epidural analgesia compared with peripheral nerve blockade after major knee surgery
E Tricarico, S Tomasino, L D’Orlando
ASS n.3 ‘Alto Friuli’, Gemona del friuli, Italy
Critical Care2009, 13(Suppl 1):P394 (doi: 10.1186/cc7558) Introduction The aim of this study was to undertake a randomized trial between lumbar continuous epidural analgesia and continuous
femoral blockade in adults undergoing major knee surgery, including comparison of analgesic efficacy [1], side effects, patient satisfaction and rehabilitation indices [2].
Methods We studied 91 patients in 2 years that were randomized into two groups: epidural group (EG) 40 and femoral group (FG) 51. All patients received spinal anesthesia with 1 ml of 1% bupiva- caine without a narcotic. The EG received a 5 ml/hour continuous infusion in elastomeric pump with 0.125% bupivacaine and morphine 20 μg/ml. The FG received a 5 ml/hour continuous infu- sion in an elastomeric pump with 0.125% bupivacaine and tramadol 1 mg/kg/day + ketorolac 30 mg intravenously x 3. Results No statistically significant difference was noted between the two groups about pain scores (VAS at rest and on movement), nausea, vomiting, arterial hypotension, morphine consumption, headache, pruritus, patient satisfaction and rehabilitation indices (active knee flexion). A statistically significant difference was noted between the two groups about contralateral analgesia, urinary retention that required bladder catheterization and motor block with major incidence in the EG.
Conclusions Continuous femoral blockade represents the best balance between analgesia and side effects as a choice of postoperative analgesic technique for major knee surgery, especially as the risk of injury to the neuraxis is negligible. Overall, however, we believe that there is no sufficient evidence that lumbar epidural analgesia should not be used routinely.
References
1. Fowler SJ, Symons J, Sabato S, Myles PS: Epidural analge- sia compared with peripheral nerve blockade after major knee surgery: a systematic review and meta-analysis of randomized trials.Br J Anaesth2008, 100:154-164. 2. Singelyn FJ, Ferrant T, Malisse MF, Joris D: Effects of intra-
venous patient-controlled analgesia with morphine, con- tinuous epidural analgesia, and continuous femoral nerve sheath block on rehabilitation after unilateral total-hip arthroplasty.Reg Anesth Pain Med2005, 30:452-457. P395
Postconditioning effects following sevoflurane inhalational sedation in the ICU: a pilot study in cardiac surgery patients
K Röhm1, J Mayer1, J Boldt1, S Suttner1, S Piper2 1Klinikum Ludwigshafen, Germany; 2Hospital of Frankenthal, Germany
Critical Care2009, 13(Suppl 1):P395 (doi: 10.1186/cc7559) Introduction Volatile anaesthetics using the anesthetic conserving device (ACD) have become an alternative ICU sedation regimen [1,2]. The purpose of this study was to evaluate postconditioning effects following sevoflurane or propofol administration in patients after elective cardiac surgery.
Methods Fifty patients either received sevoflurane via ACD or propofol for ICU sedation. The primary endpoint was a change in troponine T (TNT), besides measures of myocardial creatine kinase (CK-MB), N-terminal pro brain natriuretic peptide (NT-proBNP) and haemodynamics. Measure points were set at baseline, end of surgery, 24 hours and 48 hours after surgery.
Results TNT and CK-MB levels were significantly higher (P<0.0001) at all measure points compared with baseline in each group, without any significant differences between both groups. NT-proBNP values were significantly lower following sevoflurane at 24 and 48 hours (P <0.05) compared with propofol (Figure 1). Conclusions Postoperative sevoflurane sedation via ACD led to lower NT-proBNP levels at 24 and 48 hours, while TNT and CK- MB values were comparable in both study groups.
S161 References
1. Röhm KD, et al.: Short-term sevoflurane sedation using the Anaesthetic Conserving Device after cardiothoracic surgery. Intensive Care Med2008, 34:1673-1679.
2. Sackey PV, et al.: Prolonged isoflurane sedation of inten- sive care unit patients with the Anesthetic Conserving Device.Crit Care Med2004, 32:2241-2246.
P396
Multicenter randomized trial of sedation using daily wake-up calls, bispectral index or clinical sedation scores in a mixed medical–surgical ICU population
J Binnekade1, R Wilde2, AJ Slooter3, J Sluijs4, O Beenen3,
M Schultz1, M Dijkgraaf1, P Berg2, M Vroom1
1AMC, Amsterdam, the Netherlands; 2LUMC, Leiden, the Netherlands; 3UMCU, Utrecht, the Netherlands; 4MCH, Den Haag, the Netherlands
Critical Care2009, 13(Suppl 1):P396 (doi: 10.1186/cc7560) Introduction Daily interruption of continuous infusions of sedatives (wake-up calls (WC)) has been found previously to promote more rapid withdrawal of ventilatory support in ICU patients. Bispectral index (BIS) monitoring has been reported to adequately describe the depth of sedation in critically ill patients. We compared the effectiveness and safety of both sedation strategies in a mixed medical–surgical ICU population.
Methods Patients expected to need sedation for at least 1 day were randomly assigned to a WC strategy, sedation guided by BIS, or a control group. Clinical assessment of the sedation depth, the Ramsay score, was performed in all three groups. Primary outcome: ICU length of stay (LOS); secondary outcomes: duration of mechanical ventilation, accidental removal of indwelling devices, ICU readmission rate, hospital LOS, 90-day mortality, and stressful events (interview at ICU exit and after 3 months).
Results In four ICUs, three academic and one teaching hospital, a total number of 617 patients was randomized; 205 to the WC strategy, 202 to sedation guided by BIS, and 210 to the control group. The study groups were well balanced according to baseline characteristics. Neither ICU LOS (median (IQR) 11 (6 to 21) (WC), 12 (7 to 23) (BIS), and 11 (6 to 24) days (control),
P= 0.67) nor duration of mechanical ventilation (median 165 (0 to 581) (WC), 158 (3 to 590) (BIS), and 163 (5 to 385) hours control, P= 0.97) were different between groups. Accidental removal of indwelling devices was encountered 37 times (10 times in nine patients (WC), six times in five patients (BIS), and 21 times in 11 patients (control), P= 0.01). The ICU readmission rate, hospital LOS, and 90-day mortality were not different between groups. Interviews showed similar stress experiences.
Conclusions Although a significant higher number of incidents with indwelling devices occurred in the control group, no additional differences between the three sedation regimens were revealed. Although current guidelines on ICU sedation have incorporated WC next to clinical sedation scales, the results from this larger study do not promote either WC or BIS in guiding sedation of ICU patients.
P397
Safety and length of different sedations for endoscopic procedures
O Martinez, A Algaba, D Ballesteros, M Chana, B Estebanez, B Lopez, C Martin, L Vigil, R Blancas
Hospital del Tajo, Aranjuez, Spain
Critical Care2009, 13(Suppl 1):P397 (doi: 10.1186/cc7561) Introduction Endoscopic procedures have improved thanks to the fact that they are performed currently under sedation. We describe a series of endoscopic studies, sedated by the Intensive Care Department. Different sedation protocols are described, empha- sizing some patients sedated with ketamine plus midazolam, drugs rarely reported for adults.
Methods Patients older than 18 years, whose performed endoscopic, colonoscopic or both procedures under sedation were performed by the Intensive Care Department of the Hospital del Tajo. Data were collected for 6 months. Demographic characteristics, medical history, American Society of Anesthes- iology classification, drugs bolus and total dosages, respiratory and hemodynamic data, the length of procedure and recovery, and complications were collected. Tolerance was assessed by an endoscopist, with a 1 (very bad) to 5 (very good) scale. Different indices of two groups of treatment were compared, propofol- fentanyl (Group A) versus ketamine-midazolam (Group B) using the chi-square test and the Student t test.
Results In total, 245 procedures were included. The procedures were 168 (66.6%) colonoscopies, 34 (13.9%) endoscopies and 43 (17.6%) both procedures together. Tolerance: 33.5% were 5; 58.8% were 4; 4.5% were 3; 0.8% were 2. There were 72 (29.39%) complications, the most common hypotension being 22 (8.98%) and respiratory depression 12 (4.9%). Length of procedure was 31.20 minutes (SD = 15.53) and recovery time was 64.86 minutes (SD = 37.56). Comparing Group A versus Group B, hypotension (12.67% vs. 2.9%, P= 0.023) and respira- tory depression (6.67% vs. 0%, P = 0.03) were more frequent with Group A. Group B presented a higher percentage of vomiting (0% vs. 5.8%, P= 0.009) and hallucinations (0% vs. 11.59%,
P< 0.001). The length of recovery was longer for Group B (61.12 min vs. 78.98 min, P = 0.008).
Conclusions Sedation for endoscopic procedures performed by intensivists is safe and well tolerated for most patients, with a similar percentage of complications compared with previous reports. Ketamine plus midazolam are safe and could be useful for short-length sedation in patients with a high risk of respiratory depression.
Figure 1 (abstract P395)
S162 P398
Novel responsiveness index measures the level of sedation in cardiac ICU patients
P Lapinlampi1, H Viertiö-Oja1, M Särkelä1, K Uutela1,
P Meriläinen1, P Ramsay2, T Walsh2
1GE Healthcare, Helsinki, Finland; 2Edinburgh Royal Infirmary, Edinburgh, UK
Critical Care2009, 13(Suppl 1):P398 (doi: 10.1186/cc7562) Introduction Sedation is an integral part of the management of patients requiring mechanical ventilation in the ICU. At present, sedation is usually managed by clinical assessments, often in conjunction with a protocol for adjusting drug doses. This approach has been shown to decrease ventilation times and is considered the best practice in recent guidelines [1]. Such scales, however, provide only intermittent and, to some extent, subjective information about the patient’s state. Also, not every scale used in clinical practice is validated for ICU use and interobserver variation may occur.
Methods We have developed a novel method that analyzes the patterns in the electromyographic (EMG) component of the frontal biopotential signal that are associated with activation and arousal processes. By quantifying the amount and magnitude of the response patterns in the past 60 minutes, a responsiveness index (RI) ranging between 0 and 100 (0 corresponds to a nonresponsive patient and 100 to a high amount of responses) is derived. Previously, we have compared the RI with EEG spectral entropy [2] in general ICU patients. Now we have studied the performance of the RI with 17 cardiac ICU patients and compared these with the development dataset analyzed by Viertiö-Oja and colleagues [2]. A subgroup of 17 patients (of total 30 patients) with a clinically assessed low probability of encephalopathy was used as the primary development data. The patients in both datasets were consenting adult ICU patients with non-neurologic primary ICU diagnosis. A modified Ramsay score was used as a reference of the sedation level.
Results The performance of the RI in reference to the Ramsay scores was analyzed by computing the prediction probability (PK). The development and test data contained 213 and 96 eligible Ramsay assessments, respectively. The PK for separating deep sedation levels 4 to 6 from levels 1 to 3 was 0.91 (0.03) in the development data and 0.96 (0.02) in the test data. For separating all Ramsay levels, the PKvalues in the development data and test data were 0.82 (0.02) and 0.89 (0.02), respectively.
Conclusions These results showed good RI performance in the cardiac ICU data. The RI continues to show promise as an indicator of the level of sedation in ICU patients.
References
1. Nasraway SA, et al.: Crit Care Med2002, 30:117-118. 2. Viertiö-Oja H, et al.: Crit Care2006, 10(Suppl 1):P442. P399
Sedation protocols for intubated patients and noninvasive ventilation: additional concepts for a noniatrogenic intensive care
G Chanques, JM Constantin, B Jung, N Rossel, M Cissé, S Jaber
Saint-Eloi Hospital, Montpellier, France
Critical Care2009, 13(Suppl 1):P399 (doi: 10.1186/cc7563) Introduction Noninvasive ventilation (NIV) and sedation protocols during invasive mechanical ventilation (IMV) can both separately reduce the duration of mechanical ventilation in ICU patients.
However, no study has shown the impact of these two concepts when associated.
Methods All consecutive patients admitted to a 14-bed medical–surgical ICU were retrospectively studied from 2000 to 2006 after implementation of NIV (2000 to 2001) and sedation protocols (2003 to 2004). The duration of mechanical ventilation shown by categories was analyzed using a chi-square test. Results During the 7 years of the study, 2,839 admissions were performed in 2,511 patients (59 ± 17 years, women 36%, medical admission 43%, Simplified Acute Physiology Score II 38 ± 17, mortality in the ICU 17%). The incidence and duration of IMV significantly decreased during the study (P <0.001) (Figure 1). The NIV use progressively increased during the study period, both in medical and surgical patients.
Conclusions These results showed that the implementation of sedation protocols for intubated patients added to the imple- mentation of NIV decreased moreover the duration of IMV. P400
Does choice of sedative agent affect duration of ICU stay, mortality or neurological outcome in patients undergoing therapeutic hypothermia?
M Gillies, R Pratt, J Borg, J Brooks, C Mckenzie, S Tibby
Guy’s & St Thomas’ NHS Foundation Trust, London, UK Critical Care2009, 13(Suppl 1):P400 (doi: 10.1186/cc7564) Introduction The effect of therapeutic hypothermia on sedative drug clearance and neurological prognostication is unknown. Hypothermia has been shown to affect clearance of drugs metabolised by the cytochrome p450 system (fentanyl, midazolam and muscle relaxants) [1]. We undertook a retrospective study to ascertain whether the use of remifentanil sedation was associated with reduced duration of ICU stay, ventilation, mortality or neuro- logical outcome compared with fentanyl in patients undergoing therapeutic hypothermia.
Methods Data were collected on all patients undergoing thera- peutic hypothermia in a 2.5-year period using the Carevue ICU Database (Phillips) and case-note review. All patients received