Actividades de mayor incidencia en la variación del tiempo y el

T Hirayama, S Ichiba, K Sato, T Yumoto, K Tsukahara, M Terado, U Yoshihito, T Ugawa

Okayama University Hospital, Okayama, Japan

Critical Care 2015, 19(Suppl 1):P476 (doi: 10.1186/cc14556)

Introduction Delirium in the ICU is a predictor of mortality and cognitive impairment at hospital discharge. Although several pathways for delirium have been described, it is very diffi cult to predict the occurrence of delirium. In this study, we examined plasma biomarkers in delirious and nondelirious patients at admission and whether the biomarkers can predict onset of delirium.

Methods We targeted 103 ICU patients in Okayama University Hospital between April 2013 and February 2014. Delirium was diagnosed using the Confusion Assessment Method  – ICU. On admission, blood was obtained for biomarker analysis. Patients with severe head injury and under 16 years old were excluded. P <0.05 was considered statistically signifi cant.

Results Thirty-seven delirious and 66 nondelirious patients were included. We found that delirious patients tented to have higher B-type natriuretic peptide (BNP) levels and to have lower estimated glomerular fi ltration rate (eGFR) (BNP: delirious patients 188.6  pg/ml, nondelirious patients 78.2  pg/ml (P  = 0.001); eGFR: delirious patients 58.6  ml/ minute/1.73  m2_{, nondelirious patients 81.3  ml/minute/1.73  m}2 _{(P  =}

0.020)). Procalcitonin (PCT) and D-dimer were almost the same between delirious and nondelirious patients (PCT: delirious patients 0.202 ng/ml, nondelirious patients 0.150 ng/ml (P = 0.613); D-dimer: delirious patients 5.25 ng/ml, nondelirious patients 5.35 ng/ml (P = 0.714)).

Conclusion BNP and eGFR in ICU admission was associated with delirium. PCT and D-dimer in ICU admission was not associated with delirium. BNP and eGFR might evaluate a predictor of delirium in ICU. References

1. Ely EW, et al. JAMA. 2004;291:1753-62.

2. van den Boogaard M, et al. Crit Care. 2011;15:R297. P477

Prevalence of psychiatric disorders in trauma patients: results from a major trauma unit

M Adlam, A Feehan, V Metaxa King’s College Hospital, London, UK

Critical Care 2015, 19(Suppl 1):P477 (doi: 10.1186/cc14557)

Introduction Mental illness has been recognised as a potential risk factor both for intentional and unintentional injury. About 50% of patients presenting with self-infl icting injuries in emergency departments had previous known psychiatric disorder (PD) [1,2], whereas individuals with mental illness were admitted for unintentional injury twice as often as those without [3]. We aimed to assess the prevalence of PD in trauma patients being admitted to a major trauma ICU and compare it with the nontrauma population.

Methods We retrospectively reviewed all admissions from January 2010 to December 2013 in a tertiary, mixed ICU that serves a London major trauma centre (MTC) hospital. Data obtained were age, APACHE II score, reason for admission, length of stay (LOS), mortality and a diagnosis of depression, bipolar, self-harm, psychosis, schizophrenia and suicide attempt.

Results Of 978 trauma patients admitted to the ICU, 68 (7%) had a known PD. Their diagnoses are shown in Figure  1. Median APACHE II score and unadjusted mortality were 13 and 18% respectively in the PD group (15 and 12% in the entire cohort, P >0.05). Patients suff ering from more than one diagnosis or self-harm alone had increased median LOS (6 vs. 4 days in the entire cohort, P >0.05).

Conclusion Trauma patients with PD have increased mortality and LOS. MTCs provide a unique opportunity to identify mental illness during hospitalisation through screening and intervention programmes. Integration of mental health services into ICU care should be examined, as it might provide an effi cient and cost-eff ective way of decreasing the risk of reinjury.

References

1. Schecter WP, et al. Arch Surg. 2005;140:90. 2. Colman I, et al. Acad Emerg Med. 2004;11:136. 3. Wan JJ, et al. J Trauma. 2011;61:1299. P478

Modifi able risk factors for delirium in critically ill trauma patients: a multicenter prospective study

MA Duceppe1_{, A Elliott}1_{, M Para}1_{, MC Poirier}1_{, M Delisle}1_{, AJ Frenette}2_, D Deckelbaum1_{, T Razek}1_{, M Desjardins}2_{, JC Bertrand}2_{, F Bernard}2_{, P Rico}2_, L Burry3_{, D Williamson}2_{, MM Perreault}1

1_{The Montreal General Hospital, Montreal, QC, Canada;} 2_{Hôpital du Sacré-} Coeur de Montreal, QC, Canada; 3_{Mount Sinai Hospital, Toronto, ON, Canada} Critical Care 2015, 19(Suppl 1):P478 (doi: 10.1186/cc14558)

Introduction Delirium is associated with signifi cant morbidity and mortality in critically ill medical and surgical patients. However, patients suff ering from trauma are generally excluded from these studies. Our objectives were to assess the incidence of delirium and identify modifi able risk factors associated with delirium among critically ill trauma patients.

Methods This was a prospective observational study of trauma patients from two critical care trauma centers. We excluded patients who had ICU stay <48  hours and those with severe traumatic brain injury (TBI) (GCS ≤8). Patients were followed until ICU discharge, resolution of delirium, death or ICU length of stay >28 days. Delirium was assessed daily using the Confusion Assessment Method for the ICU until the end of the follow-up period. Demographic and admission data, daily consumption of medications, and environmental factors (that is, presence of clock, TV/radio, and so forth) were collected daily. Univariate analysis was performed using Cox regression analysis to identify risk factors for delirium. The independent eff ect of modifi able risk factors was assessed using multivariate Cox regression analysis adjusting for severity of illness and nonmodifi able risk factors. Results We enrolled 150 trauma patients resulting mostly from falls (40%) and motor vehicle accidents (28.7%) over 14  months. Patients with TBI accounted for 56.7% while polytrauma patients without TBI accounted for 43.3%. Mean ICU length of stay was 8.1 ± 7.1 days, 69.3% required mechanical ventilation, 14.7% required a tracheostomy. Delirium developed in 58 patients (38.7%) (mean age 62.9 ± 15.7, mean APACHE score 15.4 ± 6.1, mean ISS score 23.4 ± 9.1). Univariate analysis revealed that delirium was signifi cantly associated with the following nonmodifi able risk factors: age (per 10-year range), APACHE II score (per 10-point increase), need of mechanical ventilation, presence of TBI and pre-existing diabetes. In a multivariate analysis when adjusting for the nonmodifi able risk factors, opioids (adjusted HR = 0.37, 95% CI (0.14 to 1.0)), presence of a TV/radio in the room (adjusted HR = 0.28, 95% CI (0.12 to 0.67)), and number of hours mobilized (adjusted HR = 0.77, 95% CI (0.68 to 0.88)) had a protective eff ect on delirium; whereas use of physical restraints (adjusted HR = 2.20, 95% CI (1.11 to 4.35)) and active infection (adjusted HR  = 2.08, 95% CI (1.16 to 3.71)) remained strongly associated with delirium.

Conclusion Considering the long-term consequences of delirium, steps should be implemented to prevent its development in trauma and include optimizing opioids and mobilizing patients while limiting use of physical restraints.

P479

Evaluation of the PRE-DELIRIC delirium prediction tool on a general ICU

J Hanison, S Umar, K Acharya, D Conway Manchester Royal Infi rmary, Manchester, UK

Critical Care 2015, 19(Suppl 1):P479 (doi: 10.1186/cc14559)

Introduction Delirium is a frequently occurring complication of critical care, occurring in approximately 45% of unplanned UK ICU admissions Figure 1 (abstract P477).

[1]. The presence of delirium in critical care is an independent risk factor for mortality; for every day of delirium, there is an additional 10% relative risk of death at 1 year [2]. A delirium prediction tool PRE- DELIRIC has been recently developed and calibrated in a multinational project [3]. This study aimed to determine the utility of PRE-DELIRIC on our ICU.

Methods This study prospectively investigated 41 patients. Medical and surgical general ICU patients were included after 24 hours of sedation and mechanical ventilation. The researchers calculated PRE-DELIRIC scores for each patient. PRE-DELIRIC involves recording 10 variables, submitted into an online algorithm that estimates the percentage risk of delirium. We diagnosed delirium with the CAM-ICU which was performed 12 hourly [4].

Results The PRE-DELIRIC scores predicted a mean rate of delirium of 39%. PRE-DELIRIC risk scores ranged from 4 to 93% (Figure 1). Six (15%) patients developed delirium in the fi rst 24 hours following extubation. Fifteen (37%) of patients were predicted 20% or less probability of delirium. Twelve (29%) patients developed delirium at any point during their ICU stay. This resulted in 36 total delirium bed-days.

Conclusion Our observation that <30% of patients experienced delirium is less than the reported prevalence in similar settings and our own audits. This study demonstrates that there is some agreement between recorded rates of delirium and predicted rates using PRE- DELIRIC. We suggest that PRE-DELIRIC can be used in quality/audit work on UK ICUs in order to assess attempts to improve the management of delirium. Further work is required to assess the utility of PRE-DELIRIC as a risk assessment tool in individual patients.

References

1. Page VJ, et al. Routine Crit Care. 2009;13:R16.

2. Pisani MA, et al. Am J Respir Crit Care Med. 2009;180:1092-7. 3. van den Boogaard M, et al. Intensive Care Med. 2014;40:361-9. 4. Ely EW, et al. JAMA. 2001;286:2703-10.

P480

Short-term propofol infusion syndrome (PRIS): fact or fi ction? A systematic review on early PRIS in intensive care and anesthesia J Vandenbrande

University Hospitals Leuven, Belgium

Critical Care 2015, 19(Suppl 1):P480 (doi: 10.1186/cc14560)

Introduction Propofol infusion syndrome (PRIS) is a rare propofol complication, leading to cardiac failure. It was fi rst described in critically ill children and in adults with traumatic brain injury. Pathophysiology is unknown although common factors are the prolonged (>48 hours) use of high-dose (>5 mg/kg/hour) propofol combined with elevated levels of catecholamines and corticosteroids. Recently, case reports of early- onset PRIS during anesthesia and in the early postoperative setting were published. In many of these, lactic acidosis is interpreted as onset of PRIS. Criticism off ers that it might concern a poor diff erential diagnostic approach or an observational bias. Also, lactic acidosis is not an obligate PRIS symptom and incidence of lactic acidosis during propofol sedation is unknown. To gain insight into the incidence and characteristics of early PRIS, we performed a systematic review on early PRIS cases.

Methods A literature study via MEDLINE and Embase search with keywords ‘PRIS’, ‘lactic acid’, ‘propofol’ and ‘sedation’. All cases in English, French and Spanish were indentifi ed. Exclusion criteria were onset >48 hours, unclear description of time pattern and dose.

Results Twenty-two cases of early PRIS were found. These concerned 10 pediatric versus 12 adult patients. Eleven were identifi ed in the ICU versus 11 in the operating room. The survival rate of early PRIS was 95.5%, and morbidity was restricted to four patients. In the adult subgroup, the mean propofol dose was 4.9  mg/kg/hour. Triggering factors such as use of catecholamines and corticosteroids were found in 36.4% and 45% of patients. In total, 3/22 cases matched Bray’s defi nition of PRIS. In 14/22 cases, lactic acidosis was interpreted as onset of PRIS.

Conclusion Compared with a review by Fudickar [1], we found signifi cant diff erences in critical dose, risk factors, symptomatology and morbidity/mortality between PRIS and early PRIS cases. As criticisms are off ered, a question is whether these cases really are the onset of the fatal syndrome PRIS. Therefore, we completed diff erential diagnosis of lactic acidosis and found that not all possible causes (for example, hyperglycemia, ketonemia, pharmacologic confounders as biguanides, epinephrine) were ruled out in most cases. This is important since PRIS is an exclusion diagnosis. The existence of early PRIS should indeed be questioned and investigated by large, multicenter observational trials. Reference

1. Fudickar A. Propofol infusion syndrome in anaesthesia and intensive care medicine. Curr Opin Anaesthesiol. 2006;19:404-10.

P481

Propofol sedation reduces contraction and motion of diaphragm in humans: preliminary results

G Ranieri, M Luigi, F Belsito, M Rocco, RA De Blasi Sant’Andrea, Rome, Italy

Critical Care 2015, 19(Suppl 1):P481 (doi: 10.1186/cc14561)

Introduction Among drugs used for sedation, propofol has a primary role [1]. Despite propofol being described to exert a relaxant eff ect on skeletal muscle, no data showing its action on diaphragm are reported. The aim of this observational study on humans is to apply ultrasound to assess propofol’s eff ect on diaphragmatic contraction and motion during endoscopic procedures.

Methods We investigated seven consecutive patients undergoing gastroscopy or colonoscopy in the endoscopy unit of our hospital. Patients received propofol at a dose able to induce and maintain sedation to level 6 of the Ramsay Sedation Scale during the procedure. Measurements were obtained on right side of the thorax in millimeters; diaphragmatic motion (DM) and diaphragmatic motion at maximal inspiration (DM forced) were measured in M-Mode with a 3.5  MHz array convex probe placed on the midclavicular line using the liver acoustic window. Thickness at end inspiration (TEI) and thickness at end expiration (TEE) were measured in M-Mode with a 10 MHz vascular probe. The thickening fraction (TF) was calculated: (TEI – TEE) / TEE [2]. Time points of measurements were taken when the patient arrived in the surgery room (Baseline), 1  minute after level 6 of the Ramsey Sedation Scale was obtained (Sedation) and 5 minutes after the patient had a recovery to level 1 on the Ramsey Sedation Scale (Awakening). Figure 1 (abstract P479). Range of PRE-DELIRIC scores.

Table 1 (abstract P481)

Variable Baseline Sedation Awakening P value

Thickness end inspiration (mm) 3.25 (0.21) a_{2.66 (0.20)} b,c_{3.22 (0.30) <0.001*} Thickness end expiration (mm) 2.11 (0.20) d_{2.00 (0.15) 2.07 (0.15) 0.112*} Thickening fraction 0.54 (0.07) e_{0.36 (0.10)} f,g_{0.49 (0.11) <0.001*} Diaphragmatic motion (mm) 18.66 (2.23) h_{13.27 (4.93) 15.31 (0.40) 0.055} Diaphragmatic motion forced 54.61 (19.34) – 56.34 (13.75) 0.298 (mm)

a_{P <0.001 versus baseline.} b_{P = 0.043 versus baseline.} c_{P <0.001 versus sedation.} d_{P = 0.030 versus baseline.} e_{P =0.012 versus baseline.} f_{P =0.353 versus baseline.} g_{P = 0.041 versus sedation.} h_{P = 0.022 versus baseline.}

Data analyzed are reported in Table  1 and expressed as mean (SD). *ANOVA was used to compare data for repeated measurements. Post hoc statistical comparison with Bonferroni’s test was used to identify signifi cant variations.

Results During propofol administration TEI reduced 19% whereas after awakening it increased 14.5% but did not reach baseline. Conversely TEE did not change during the study. During propofol sedation, TF decreased 34% and returned to baseline after recovery. DM showed 29% reduction during propofol administration whereas the forced diaphragmatic motion tested when patients were conscious (forced DM) did not evidence any change.

Conclusion In this observational study, ultrasound assessed that propofol causes a reduction of diaphragmatic contraction and motion during endoscopic procedures.

References

1. Singh H, et al. Cochrane Database Syst Rev. 2008;4:CD006268. 2. Matamis D, et al. Intensive Care Med. 2013;39:801-10.

P482

Delirium knowledge and assessment by ICU practitioners in South Africa: results of a national survey

S Chetty, F Paruk

University of the Witwatersrand, Johannesburg, South Africa Critical Care 2015, 19(Suppl 1):P482 (doi: 10.1186/cc14562)

Introduction Delirium recognition in critically ill patients is considered to be important taking into account the poor outcomes associated with its occurrence. The purpose of this study was to evaluate knowledge pertaining to delirium as well as the implementation of screening practices. This study constituted a component of a survey that explored current sedation-related practices in South African ICUs.

Methods Following approval from the University Human Research ethics committee, a validated questionnaire was distributed electronically to physician members of various medical databases in South Africa as South Africa does not have a formal registry of critical care practitioners.

Results One hundred and twenty-six of 174 respondents indicated that they practice in the ICU setting. Sixty-six per cent were specialists and mainly anaesthesiologists (42%), whilst 32% were critical care subspecialists. The respondents indicated that on average 30 ± 20% of their patients experience delirium. Eighty per cent of the respondents indicated that delirium impacts signifi cantly negatively on patient outcomes whilst 1% indicated that there was no such association. Delirium screening is achieved mainly by clinical assessment (77%). Twenty-four per cent utilise an objective tool to screen for delirium and amongst them the CAM-ICU is utilised by 80%. Amongst delirious patients the sedative of choice is dexmedetomidine in the majority. However, 20% prescribe midazolam as a fi rst choice in this setting. Conclusion The fi ndings are comparable with reports of similar surveys conducted in other regions. The delirium screening method is inadequate as the vast majority do not utilise an objective method.

P483

Loxapine to control agitation during weaning from mechanical ventilation: a randomized controlled trial

S Gaudry1_{, B Sztrymf}2_{, R Sonneville}3_{, B Megarbanne}4_{, C Clec’h}5_{, J Ricard}1_, D Hajage3_{, D Dreyfuss}1

1_{Hôpital Louis Mourier, Colombes, France;} 2_{Hôpital Béclère, Clamart, France;} 3_{Hôpital Bichat, Paris, France;} 4_{Hôpital Lariboisière, Paris, France;} 5_Hôpital Avicennes, Bobigny, France

Critical Care 2015, 19(Suppl 1):P483 (doi: 10.1186/cc14563)

Introduction Weaning from prolonged mechanical ventilation (MV) in the ICU may be impeded by the occurrence of agitation. Loxapine had the ability to control agitation without aff ecting the effi cacy of spontaneous ventilation in an observational study, justifying the implementation of a randomized controlled trial.

Methods We conducted a multicenter, placebo-controlled, parallel group, randomized trial at fi ve French ICUs between November 2011 and November 2013. Patients (aged >18  years) under MV for more

than 48  hours who were potential candidates for weaning from the ventilator and who exhibited agitation defi ned by a Richmond Agitation Sedation Scale (RASS) >2 after sedation withdrawal were randomly assigned to receive either loxapine or placebo. All participants were masked to group of allocation. After randomization, patients received 150 mg loxapine or placebo by nasogastric tube. RASS was monitored every 4 hours. A second dose of loxapine or placebo was administered if agitation persisted or worsened. In case of severe agitation, usual sedation (benzodiazepines and morphinic agents) was immediately resumed. Extubation was contemplated when patients were conscious and calm. The primary endpoint was the time between the fi rst administration of loxapine or placebo and successful extubation (no reintubation in the following 48 hours). Three hundred patients were necessary to have 90% power to detect a 2-day reduction of weaning time in the loxapine group with a one-sided type I error rate of 5%. Results The trial was discontinued after 101 patients had been randomized because of insuffi cient enrollment. Fifteen patients withdrew consent, leaving 86 patients for analysis. Forty-seven patients were assigned to the loxapine group and 39 to the placebo group. Median time to successful extubation was 3.2  days in the loxapine group and 5  days in the placebo group (RR  = 1.2, 95% CI  = 0.75 to 1.88; P = 0.45). During the fi rst 24 hours, sedation was more frequently resumed in the placebo group (44% vs. 17%, P = 0.01). One patient had a transient seizure in the loxapine group.

Conclusion These results are consistent with the hypothesis of 2 days reduction of the median weaning time in the loxapine group, but the diff erence was not statistically signifi cant. Loxapine reduces the need for resuming sedation during weaning from MV. Given the quality of the data and methodology, these results may be useful in future meta-analyses.

P484

Prolonged dexmedetomidine infusion and drug withdrawal in critically ill children

A Haenecour, A Goodwin, W Seto, C Urbain, P Laussen, C Balit The Hospital for Sick Children, Toronto, ON, Canada

Critical Care 2015, 19(Suppl 1):P484 (doi: 10.1186/cc14564)

Introduction We investigated the incidence, symptoms and risk factors for withdrawal associated with prolonged dexmedetomidine use. Dexmedetomidine is an α2-adrenergic receptor agonist, with anxiolytic,

analgesic and sedative properties. Intended for short-term use, there is increasing literature describing prolonged use for sedation. However, this raises the potential of withdrawal syndrome and there is no recommendation for the discontinuation of dexmedetomidine. Other goals included determining the hemodynamic eff ects of discontinuation of dexmedetomidine and role of clonidine in patients with prolonged dexmedetomidine use.

Methods A retrospective review of patients admitted to the critical care unit who had exposure to dexmedetomidine for longer than 48  hours, between 1 January 2014 and 15 July 2014. Data included patient demographics, dexmedetomidine exposure (bolus dose, total cumulative dose, duration), other sedative exposure, withdrawal symptoms measured by WAT-1 score, nursing subjective assessment and treatment given for withdrawal. Each potential withdrawal episode was reviewed by two reviewers. Hemodynamic parameters were analyzed to assess hemodynamic changes associated with discontinuation of dexmedetomidine. Descriptive statistics were used