French Intensive Care Society, International congress – Réanimation 2016
2016; Springer Nature; Volume: 6; Issue: S1 Linguagem: Inglês
10.1186/s13613-016-0114-z
ISSN2110-5820
AutoresAlain Ducousso‐Lacaze, Dolores Albarracín, Angéline Jamet, Julien Dufour, Séverin Cabasson, Anne Veinstein, Delphine Chatellier, Jean‐Pierre Frat, René Robert,
Tópico(s)Intensive Care Unit Cognitive Disorders
ResumoPHYSICIANS ABSTRACTSO1 Impact of tracheal cuff shape on microaspiration of gastric contents in intubated critically ill patients: a multicenter randomized controlled study (BEST CUFF)Emmanuelle Jaillette, Christophe Girault, Guillaume Brunin, Farid Zerimech, Arnaud Chiche, Céline Broucqsault-Dedrie, Cyril Fayolle, Franck Minacori, Isabelle Alves, Stephanie Barrailler, Laurent Robriquet, Fabienne Tamion, Emmanuel Delaporte, Damien Thellier, Claire Delcourte, Alain Duhamel & Saad Nseir Centre de réanimation, C.h.r.u. Lille, Lille, FranceEmmanuelle Jaillette, Laurent Robriquet, Claire Delcourte & Saad NseirRéanimation Médicale, Centre Hospitalier Universitaire Rouen, Rouen, FranceChristophe GiraultReanimation, Hospital Center De Boulogne-Sur-Mer, Boulogne-sur-Mer, FranceGuillaume Brunin & Emmanuel DelaporteLaboratoire de biochimie et biologie moléculaire, C.h.r.u. Lille, Lille, FranceFarid ZerimechRéanimation, Centre Hospitalier de Tourcoing, Tourcoing, FranceArnaud Chiche & Damien ThellierRéanimation, Hôpital Victor Provo, Roubaix, FranceCéline Broucqsault-DedrieReanimation, Hospital Center De Dunkerque, Dunkerque, FranceCyril FayolleReanimation, Hospital Saint Philibert, Lille, FranceFranck MinacoriReanimation, Hospital Center De Valenciennes, Valenciennes, FranceIsabelle AlvesReanimation, C.H. de Lens, Lens, FranceStephanie BarraillerRéanimation médicale, Hospital Center University Rouen, Rouen, FranceFabienne TamionClinique de santé publique, plateforme d'aide méthodologique, C.h.r.u. Lille, Lille, FranceAlain DuhamelCorrespondence: Emmanuelle Jaillette - emmanuelle.jaillette@chru-lille.frAnnals of Intensive Care 2016, 6(Suppl 1):O1Introduction Ventilator-associated pneumonia (VAP) is the most common ICU-acquired infection in intubated critically ill patients. Microaspiration of gastric and oropharyngeal contaminated secretions represents the primary mechanism involved in the pathogenesis of VAP. Tracheal cuff plays an important role in stopping the progression of contaminated secretions into the lower respiratory tract. In vitro and animal studies suggested that leakage was significantly reduced with polyvinyl chloride (PVC) conical-cuffed tubes compared with barrel (standard) or cylindrical cuffs. Clinical studies found conflicting results. Therefore, the aim of this study is to determine the superiority of PVC conical- versus barrel (standard)-cuffed tracheal tube on abundant microaspiration of gastric contents in intubated critically ill patients.Materials and methods BEST CUFF is a prospective multicenter (ten French ICUs) cluster randomized controlled crossover and open-label trial performed in patients with predicted duration of mechanical ventilation ≥48 h. Patients were allocated to be intubated using a PVC standard (barrel)-shaped or a PVC conical-shaped tracheal tube. Prevention measures of VAP were standardized in all ICUs. The main objective was to demonstrate the superiority of conical versus standard cuff shape in reducing abundant microaspiration of gastric contents (pepsin level >200 ng/ml in at least 30 % of tracheal aspirates). After inclusion, tracheal aspirates were collected for 48 h to measure pepsin and salivary amylase, and diagnose gastric and oropharyngeal microaspiration. To diagnose tracheobronchial colonization, quantitative aspirate was performed after intubation and two times a week until extubation. In patients with suspected VAP, quantitative tracheal aspirate or bronchoalveolar lavage was performed to confirm the diagnosis. We hypothesized that the use of conical-cuffed tracheal tubes would reduce the incidence of abundant microaspiration of gastric contents from 50 to 30 % of study patients. With a two-sided alpha risk of 5 %, a power of 80 %, and to account for an anticipated rate of 10 % of patients without any tracheal secretions, 312 patients had to be recruited.Results A total of 326 patients were included during the study period (June 2014–September 2015). Pepsin and salivary amylase measurement is actually performed, and all results should be available in November 2015. Statistical analyses will be performed in mid-December, and study results will be presented at the 2016 Réanimation Congress.Discussion Our study is sufficiently powered to detect a significant difference in microaspiration of gastric contents between patients intubated with conical-cuffed tracheal tubes and standard-cuffed tracheal tubes. One of the strengths of this study is the use of quantitative measurement of pepsin as a marker of microaspiration.Conclusion BEST CUFF is the first randomized controlled study evaluating the impact of PVC tracheal cuff shape on microaspiration of gastric contents. The results will be presented at the 2016 Réanimation Congress.Competing interests None.O2 Bicarbonate versus saline for contrast-induced acute kidney injury prevention in critically ill patientsXavier Valette, Isabelle Desmeulles, Benoit Savary, Romain Masson, Amélie Seguin, Cédric Daubin, Bertrand Sauneuf, Jennifer Brunet, Pierre Verrier, Véronique Pottier, Marie Orabona, Désiré Samba, Gérald Viquesnel, Mathilde Lermuzeaux, Pascal Hazera, Jean-Luc Hanouz, Jean-Jacques Parienti & Damien Du Cheyron Réanimation médicale, C.H.U de Caen, Caen, FranceXavier Valette, Amélie Seguin, Cédric Daubin, Bertrand Sauneuf, Pierre Verrier & Damien Du CheyronRéanimation chirurgicale, C.H.U de Caen, Caen, FranceIsabelle Desmeulles, Romain Masson, Jennifer Brunet, Véronique Pottier, Marie Orabona, Désiré Samba, Gérald Viquesnel, Mathilde Lermuzeaux & Jean-Luc HanouzRéanimation polyvalente, C.H. Mémorial France - Etats-Unis (Saint-Lô), Saint-Lô, FranceBenoit Savary & Pascal HazeraUnité de biostatistique et de recherche clinique, C.H.U de Caen, Caen, FranceJean-Jacques ParientiCorrespondence: Xavier Valette - valette3l2ax@sfr.frAnnals of Intensive Care 2016, 6(Suppl 1):O2Introduction The administration of contrast media for imaging and interventional procedures is frequent in intensive care unit (ICU). Whether volume expansion with bicarbonate is better than isotonic saline to reduce the risk of contrast-induced acute kidney injury (CI-AKI) in critically ill patients is unknown.Materials and methods The HYDRAREA study was a randomized, double-blind, multicenter trial including adults admitted in three ICUs in France who received intravascular contrast media. Patients with unstable renal function (increase in serum creatinine level of at least 0.3 mg/dL during the previous 48 h, anuria during the previous 12 h, renal replacement therapy) or contraindication to volume expansion or bicarbonate load (uncontrolled cardiogenic pulmonary edema, metabolic alkalosis with pH >7.50, hypokalemia <3 mmol/L, chronic hypercapnia) were not included. Patients were randomized in a 1:1 ratio to receive 0.9 % sodium chloride or 1.4 % sodium bicarbonate administered with the same infusion protocol: 3 mL/kg for 1 h started before contrast media administration followed by 1 mL/kg/h for 6 h. The primary outcome was the incidence of CI-AKI defined by the Acute Kidney Injury Network criteria within 72 h after contrast medium administration. Secondary outcomes included CI-AKI using alternative definitions (AKIN without urine output criteria, RIFLE classification, creatinine increase ≥0.5 mg/dL or 25 %), need for renal replacement therapy, ICU length of stay and mortality.Results Among the 307 patients randomized, the mean (SD) age was 56 ± 15 years and 208 (68 %) patients were male. Patients were admitted in ICU for medical reason in 132 (43 %) patients, for emergency surgery in 118 (38 %) patients, following trauma in 45 (15 %) patients and after a scheduled surgery in 12 (4 %) patients. The mean (SD) SAPS II and SOFA scores at ICU admission were 42 ± 17 and 7 ± 4, respectively. Contrast media were used for computed tomography in 193 (63 %) patients and for arteriography in 114 (37 %) patients. Low-osmolar contrast media were used in 276 (90 %) patients. At randomization, 243 (79 %) patients were under mechanical ventilation, 100 (33 %) patients needed vasopressor, 104 (34 %) patients had sepsis, and 40 (13 %) patients had a RIFLE stage equal or higher than the "Risk of Kidney Injury" class. Patient characteristics were well balanced between groups excepted for the use of nephrotoxic medications which was more common in saline group (40 (26 %) patients vs 59 (38 %) patients; p < 0.05).As expected, patients receiving bicarbonate (n = 151) had higher urinary pH at the end of the infusion than patients receiving saline (n = 156) (6.7 ± 2.1 vs 6.2 ± 1.8, respectively; p < 0.001). The incidence of CI-AKI was similar in both groups: 52 (33.3 %) patients in saline group and 53 (35 %) patients in bicarbonate group (RR 0.96; 95 % CI [0.70–1.30]; p = 0.81). There was no difference between groups whatever the definition used to define CI-AKI. The need for renal replacement therapy (five (3.2 %) patients in saline group vs six (4 %) patients in bicarbonate group; RR 0.81; 95 % CI [0.25–2.59]; p = 0.77), ICU length of stay (24.7 ± 22.9 days in saline group vs 23 ± 23.8 days in bicarbonate group, p = 0.52) and mortality (25 (16 %) patients in saline group vs 24 (15.9 %) patients in bicarbonate group; RR 1.00; 95 % CI [0.60–1.68]; p = 0.97) were also similar between groups.Conclusion Hydration with sodium bicarbonate for CI-AKI prevention in critically ill patients does not provide supplementary beneficial effect in comparison with hydration by isotonic sodium chloride.Competing interests None.O3 Neurally adjusted ventilatory assist in the early phase of weaning from mechanical ventilation: a multicenter randomized studyAlexandre Demoule, Marc Clavel, Camille Rolland-Debord, Sébastien Perbet, Nicolas Terzi, Achille Kouatchet, Florent Wallet, Hadrien Roze, Frédéric Vargas, Claude Guérin, Jean Dellamonica, Samir Jaber & Thomas Similowski Intensive Care and Respiratory Division, Pitié-Salpêtrière Hospital, Paris, FranceAlexandre Demoule & Camille Rolland-DebordService de réanimation polyvalente, Centre Hospitalier Universitaire de Limoges, Limoges, FranceMarc ClavelService de réanimation adultes, C.H.U. Estaing, Clermont-Ferrand, FranceSébastien PerbetService de réanimation médicale, Clinique de Réanimation Médicale, Grenoble, FranceNicolas TerziRéanimation médicale, Centre Hospitalier Universitaire d'Angers, Angers, FranceAchille KouatchetRéanimation médicale et chirurgicale, CHU Lyon Sud, Lyon, FranceFlorent WalletSar 2, unité réanimation thoracique greffe, CHU de Bordeaux, Bordeaux, FranceHadrien RozeRéanimation médicale, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, FranceFrédéric VargasRéanimation médicale, Hôpital de la Croix-Rousse, Lyon, FranceClaude GuérinRéanimation médicale, Centre Hospitalier Universitaire Archet, Nice, FranceJean DellamonicaDAR B, Hôpital Saint Eloi, Montpellier, FranceSamir JaberService de pneumologie et réanimation médicale, Groupe Hospitalier Pitié-Salpêtrière, Paris, FranceThomas SimilowskiCorrespondence: Alexandre Demoule - alexandre.demoule@aphp.frAnnals of Intensive Care 2016, 6(Suppl 1):O3Introduction Neurally adjusted ventilatory assist (NAVA) is a ventilatory mode that tailors the level of assistance delivered by the ventilator to the electromyographic activity of the diaphragm. The objective of the present study was to compare the impact of mechanical ventilation with NAVA or pressure support ventilation (PSV) on the early phase of weaning from mechanical ventilation.Patients and methods A multicenter randomized controlled trial of 128 intubated adults recovering from an acute respiratory failure was conducted in 11 intensive care units (ICUs) from April 2010 to June 2012. Patients were randomly assigned to NAVA or PSV. The primary endpoint was the probability to remain in an assisted mode during the entire first 48 h. Secondary endpoints included asynchrony index, duration of mechanical ventilation and hospital mortality at 28 days.Results The proportion of patients remaining in an assisted mode during the entire first 48 h was 67.7 % in the NAVA group versus 69.4 % in the PSV group (p = 0.47). The time spend in an assisted mode similar in the two groups (47 [43–48] vs. 47 [40–48], p = 0.55). The asynchrony index was lower in the NAVA group (19.7 vs. 32.6 %). Duration of mechanical ventilation was similar in the two groups (12.0 [7.0–17.0] in the NAVA group vs. 13.5 [10.0–21.0] in the PSV group, p = 0.121) as was the ICU mortality rate (12.9 vs. 21.2 %, p = 0.21). More patients required post-extubation noninvasive mechanical ventilation in the PSV group (66.6 vs. 43.5 %, p = 0.008).Conclusion NAVA can be applied efficiently in a clinical setting and improves patient ventilator interaction. However, NAVA does not increase the probability to remain in an assisted mode during the first 48 h.Competing interests A. Demoule: reserche contract with Maquet, Drager, Philips, Covidien. Consulting for Covidien. Speaker for Covidien.O4 Very high volume hemofiltration with the Cascade system in septic shock patientsJean-Pierre Quenot, Christine Binquet, Christophe Vinsonneau, Saber-Davide Barbar, Sandrine Vinault, Valérie Deckert, Stephanie Lemaire, Ali Ait Hssain, Rémi Bruyère, Bertrand Souweine, Laurent Lagrost & Christophe Adrie Réanimation médicale, CHU Dijon, Dijon, FranceJean-Pierre QuenotCentre d'investigation clinique, Chu Dijon, Dijon, FranceChristine Binquet & Sandrine VinaultRéanimation polyvalente, Centre Hospitalier Marc Jacquet, Melun, FranceChristophe Vinsonneau30, Chru De Nîmes, Nîmes, FranceSaber-Davide Barbar21, Faculté de médecine, Dijon, FranceValérie Deckert, Stephanie Lemaire & Laurent LagrostRéanimation médicale, CHU Gabriel-Montpied, Clermont-Ferrand, FranceAli Ait Hssain & Bertrand Souweine01, CH de Fleyrat, Bourg-en-Bresse, FranceRémi BruyèrePhysiologie, Hôpital Cochin, Paris, FranceChristophe AdrieCorrespondence: Jean-Pierre Quenot - jean-pierre.quenot@chu-dijon.frAnnals of Intensive Care 2016, 6(Suppl 1):O4Introduction We compared hemodynamic and biological effects of the Cascade system, which uses very high volume hemofiltration (HVHF) (120 ml/kg/h), with those of usual care in patients with septic shock.Patients and methods Multicenter, prospective, randomized, open-label trial was conducted in three intensive care units (ICU). Adults with septic shock with administration of epinephrine/norepinephrine were eligible. Patients were randomized to usual care plus HVHF (Cascade group) or usual care alone (Control group). Primary endpoint was the number of catecholamine-free days up to 28 days after randomization. Secondary endpoints were number of days free of mechanical ventilation, renal replacement therapy (RRT) or ICU up to 90 days, and 7-, 28- and 90-day mortality.Results We included 60 patients (29 Cascade and 31 usual care). Baseline characteristics were comparable. Median number of catecholamine-free days was 22 [IQR 11–23] versus 20 [0–25] for Cascade versus Control; there was no significant difference even after adjustment. There was no significant difference in number of mechanical ventilation-free days or ICU requirement. Median number of RRT-free days was 85 [46–90] versus 74 [0–90] for Cascade versus Control groups, p = 0.42. By multivariate analysis, the number of RRT-free days was significantly higher in the Cascade group (up to 25 days higher after adjustment). There was no difference in mortality at 7, 28 or 90 days.Conclusion Very HVHF using the Cascade system can safely be used in patients presenting septic shock, but was not associated with a reduction in the need for catecholamines during the first 28 days.Competing interests None.O5 Effect of rapid response systems on hospital mortality, a prospective interventional study and systematic reviewBoris Jung, Aurelien Daurat, Audrey De Jong, Gérald Chanques, Martin Mahul, Marion Monnin, Nicolas Molinari & Samir Jaber Dar b, Hôpital Saint Eloi, Montpellier, FranceBoris Jung, Aurelien Daurat, Audrey De Jong, Gérald Chanques, Martin Mahul & Samir JaberDar b, CHRU Hôpital Saint Eloi, Montpellier, FranceMarion MonninDim, Hôpital La Colombière, Montpellier, FranceNicolas MolinariCorrespondence: Boris Jung - boris.jung@me.comAnnals of Intensive Care 2016, 6(Suppl 1):O5Introduction Although rapid response systems (RRSs) are known to reduce in hospital cardiac arrest rate, their effect on mortality remains in question. The present study aimed at evaluating the effect of a medical emergency team (MET) implementation on mortality in hospitalized patients.Patients and methods A prospective study was conducted in the four hospitals of the regional healthcare center of Montpellier, France. An intensivist-led MET was implemented on a 24/7 basis in only one of the four hospitals from January 2012 to June 2012. Patients >18 years admitted for more than 24 h in the medical-surgical wards from July 2010 to December 2011 (pre-MET period) and from July 2012 to December 2013 (MET period) were included. The main outcome was unexpected mortality in hospitalized patients. An updated systematic review and meta-analysis were also performed.Results A total of 137,251 patients were admitted for 24 h or more in the medical-surgical wards during the pre-MET and MET periods. MET implementation was associated with a decrease in unexpected mortality rate in the hospital that implemented MET (from 21.9 to 17.4 per 1000 admissions; P = 0.002). Reduction in unexpected mortality associated with MET implementation could be estimated at 1.5 lives saved per week in the MET hospital. In the three other hospitals, mortality rate was not significantly modified (from 19.5 to 19.9 per 1000 admissions; P = 0.69). Patients in the MET hospital were more frequently admitted to the intensive care unit (ICU) during the MET period (45.8 vs 52.9 per 1000; P = 0.002), and their sequential organ failure assessment (SOFA) score upon ICU admission significantly decreased from 7 [4–10] to 5 [2–9]; P < 0.001. The updated meta-analysis including the present results showed that RRS was associated with a significant decrease in both unexpected (OR 0.51; 95 % CI 0.35–0.76) and overall mortality (OR 0.89; 95 % CI 0.85–0.93).Conclusion In the present prospective study, implementation of a MET was associated with a decrease in unexpected and overall mortality. Updated meta-analysis confirms the benefit of RRS on unexpected and overall mortality (Fig. 1). Fig. 1Evolution of unexpected death rate per 1000 admissions by month in the MET pavilion (left side) and in the three other pavilions (right side). Dotted lines represent the mean rate per month. Grey rectangles represent the standard deviationsFull size image Competing interests None.O6 Beta-lactams serum concentrations in critically ill cirrhotic patients: a matched control studyOlivier Lheureux, Eric Trepo, Maya Hites, Frederic Cotton, Fleur Wolff, Rudy Surin, Jacques Créteur, Jean-Louis Vincent, Thierry Gustot, Frederique Jacobs & Fabio Silvio Taccone Service de soins intensifs, Hospital Erasme, Brussel, BelgiumOlivier Lheureux, Jacques Créteur, Jean-Louis Vincent & Fabio Silvio TacconeService de gastroentérologie, Hospital Erasme, Brussel, BelgiumEric Trepo & Thierry GustotService de maladies infectieuses, Hospital Erasme, Brussel, BelgiumMaya Hites, Rudy Surin & Frederique JacobsService de biochimie médicale, Hospital Erasme, Brussel, BelgiumFrederic Cotton & Fleur WolffCorrespondence: Olivier Lheureux - olheureu@ulb.ac.beAnnals of Intensive Care 2016, 6(Suppl 1):O6Introduction Few data are available on the pharmacokinetics of β-lactams in critically ill cirrhotic patients. The objective of this study was to evaluate whether β-lactam concentrations were altered in patients with cirrhosis compared with other critically ill patients and to identify the principal risk factors for any differences.Materials and methods We reviewed data from critically ill cirrhotic patients and matched controls in which routine therapeutic drug monitoring of broad-spectrum β-lactam antibiotics (piperacillin/tazobactam; meropenem) was performed. Serum drug concentrations were measured twice during the elimination phase by high-performance liquid chromatography. Antibiotic pharmacokinetics was calculated using a one-compartment model. We considered therapy was adequate when serum drug concentrations were between 4 and 8 times the minimal inhibitory concentration of Pseudomonas aeruginosa during optimal periods of time for each drug ≥50 % for piperacillin/tazobactam; ≥40 % for meropenem).Results We studied 38 cirrhotic patients (16 for piperacillin/tazobactam and 22 for meropenem) and 38 matched controls. Drug dosing was similar in the two groups. The pharmacokinetic analysis showed a lower volume of distribution of meropenem (p = 0.05) and a lower antibiotic clearance of piperacillin/tazobactam (p = 0.009) in patients with cirrhosis when compared to non-cirrhotic patients. Patients with cirrhosis more often had excessive (23/38) than insufficient (5/38) or adequate (10/38) serum β-lactam concentrations; they also had excessive drug concentrations more frequently than did control patients (23/38 vs. 13/38—p = 0.02), particularly for piperacillin/tazobactam (9/16 vs. 2/16—p = 0.01). The only variable significantly associated with insufficient drug concentrations was the creatinine clearance on the day of the therapeutic drug monitoring. No specific variable was associated with excessive drug concentrations.Conclusion This case–control study shows that standard doses of β-lactams result in excessive serum concentrations in two-thirds of critically ill patients with cirrhosis, especially in those treated with piperacillin/tazobactam. Our results support routine β-lactam therapeutic drug monitoring in this patient population.Competing interests None.References1. Roberts JA, Paul SK, Akova M, Bassetti M, De Waele JJ, Dimopoulos G et al. DALI: defining antibiotic levels in intensive care unit patients: are current β-lactam antibiotic doses sufficient for critically ill patients? Clin Infect Dis. 2014;58(8):1072–1083.2. Gustot T, Felleiter P, Pickkers P, Sakr Y, Rello J, Velissaris D et al. Impact of infection on the prognosis of critically ill cirrhotic patients: results from a large worldwide study. Liver Int. 2014;34(10):1496–1503.O7 Systematic overdosing of oxa- and cloxacillin in severe infections treated in ICU: Risk factors and side effectsMathilde Neuville, Jean-François Timsit, Najoua El-Helali, Alban Le Monnier, Eric Magalhaes, Aguila Radjou, Roland Smonig, Jean-François Soubirou, Guillaume Voiriot, Romain Sonneville, Lila Bouadma & Bruno Mourvillier Réanimation médicale et infectieuse, Hôpital Bichat-Claude Bernard, Paris, FranceMathilde Neuville, Jean-François Timsit, Eric Magalhaes, Aguila Radjou, Roland Smonig, Jean-François Soubirou, Guillaume Voiriot, Romain Sonneville, Lila Bouadma & Bruno MourvillierUnité de microbiologie clinique et dosages des anti-infectieux, Groupe hospitalier Paris Saint-Joseph, Paris, FranceNajoua El-Helali & Alban Le MonnierCorrespondence: Mathilde Neuville - mathilde.neuville@aphp.frAnnals of Intensive Care 2016, 6(Suppl 1):O7Introduction Oxacillin and cloxacillin are the most frequently used penicillins for the treatment of severe methicillin-susceptible Staphylococcus aureus (MSSA) infections in intensive care units (ICU), especially endocarditis. No adaptation of the dosage is required in case of renal failure. We wanted to assess the risk factors for overdosing in ICU, and the related observed side effects.Patients and methods All patients with a therapeutic drug monitoring (TDM) of oxa- or cloxa-cillin between 2008 and 2014 were included. The optimal trough concentration was considered to be 20 mg/L, i.e., 10 times the minimum inhibitory concentration of cloxaxillin for MSSA. Data concerning the medical history, the characteristics of the infection, the given treatment, the renal function and the attributed side effects of overdosing were collected. A negative binomial model was used to compute the measured trough concentrations.Results Sixty-two patients were included in this study. We found a median trough plasma concentration of 134.3 mg/L [IQR 65.3–201 mg/L]. Only one patient reached the target concentration; all other patients were overdosed. Eleven patients (17.7 %) experienced neurological side effects attributed to a high antibiotic concentration, i.e., persistent coma and delirium. When adjusted on the dosage used, the first trough concentration was significantly increased by a creatinine clearance below 10 ml/min (with or without hemodialysis) and by endocarditis as the source of infection (Fig. 2). Fig. 2Univariate and multivariate statistical analysis. Day 0 = day of ICU admission, T-day = day of treatment initiation, D-day = day of TDMFull size image Conclusion With the recommended dose of 12 g/day for cloxacillin treatment in case of endocarditis and severe infections occurring in ICU, almost all patients are largely overdosed. Considering the high frequency of observed side effects, doses should be accurately monitored and reduced, particularly when renal replacement therapy is needed.Competing interests None.O8 Amikacin peak concentrations in patients receiving extracorporeal membrane oxygenation (ECMO) support: a case–control studyElodie Gélisse, Mathilde Neuville, Etienne De Montmollin, Guillaume Voiriot, Jean-François Soubirou, Roland Smonig, Aguila Radjou, Eric Magalhaes, Lila Bouadma, Bruno Mourvillier, Jean-François Timsit & Romain Sonneville Unité de réanimation robert debré, CHU Reims, Reims, FranceElodie GélisseService de réanimation médicale et infectieuse, Hôpital Bichat-Claude Bernard-APHP, Paris, FranceMathilde Neuville, Guillaume Voiriot, Jean-François Soubirou, Roland Smonig, Aguila Radjou, Eric Magalhaes, Lila Bouadma, Bruno Mourvillier, Jean-François Timsit & Romain SonnevilleRéanimation, C.H. Général Saint Denis hôpital Delafontaine, Saint-Denis, FranceEtienne De MontmollinCorrespondence: Elodie Gélisse - elodie.gelisse@gmail.comAnnals of Intensive Care 2016, 6(Suppl 1):O8Introduction More than half of adult patients receiving extracorporeal membrane oxygenation (ECMO) require an antibiotic therapy during their stay in ICU. Amikacin is the most used aminoglycoside for the treatment of septic shock given its good bactericidal activity on Pseudomonas aeruginosa and the low resistance rate observed with the other Gram-negative bacilli. However, data on pharmacokinetics of amikacin in patients receiving ECMO support have scantly been studied in these conditions. We aimed to report on the distribution of peak serum concentration (Cmax) of amikacin and on factors associated with insufficient Cmax in a population of critically ill patients receiving ECMO.Materials and methods We conducted an observational single-center study of patients admitted to a general ICU. Inclusion criteria were: (1) age ≥18 years and (2) a suspected Gram-negative infection requiring a loading dose of intravenous amikacin. Amikacin was routinely administered intravenously at a dose of 25 mg/kg of total body weight over a 30-min infusion time. Cmax was measured 30 min after the end of infusion and trough serum concentration 24 h after the end of infusion (Cmin). ECMO patients were matched with critically ill patients without ECMO support (controls) for characteristics that had been previously identified as independent predictors for insufficient Cmax, namely body mass index (BMI), cirrhosis and 24-h fluid balance. An amikacin Cmax >60 mg/L and <80 mg/l was considered the target concentration (adequate drug concentrations). An amikacin Cmax 80 mg/l was considered as an excessive one. The primary outcome was the distribution of Cmax (mg/L) between ECMO patients and controls.Results A total of 50 episodes in 46 ECMO patients were matched with 50 controls. Baseline characteristics did not differ between groups, except for age (61 vs. 63.5 years), reason for ICU admission and SOFA score (12 [10–14] vs. 9 [6–11]). At the day of Cmax, in ECMO patients the SOFA score was 9 [5.3–9.8], and 100 % episodes required mechanical ventilation, 96 % vasopressors and 44 % renal replacement therapy. There were no significant differences in serum concentrations between ECMO and non-ECMO patients: The amikacin Cmax was 71.7 [58.9–79.7] mg/l for ECMO patients versus 68.4 [53–81] mg/l for non-ECMO patients (p = 0.36). The proportion of insufficient [13/50 (26 %) episodes vs. 17/50 (34 %) episodes), adequate (25/50 (50 %) episodes vs. 18/50 (36 %) episodes] and excessive [12/50 (24 %) episodes vs. 15/50 (30 %) episodes] drug concentrations was similar in ECMO and non-ECMO patients (Table 1). Cmin was measured in 43 (86 %) episodes, and 28/43 (65 %) measurements were above the toxic threshold of 5 mg/L in ECMO patients versus 30/50 (60 %) in non-ECMO patients. Table 1 Episodes characteristics at ICU admission and time of C max Full size table Conclusion ECMO therapy did not significantly impact on peak and trough serum concentrations of amikacin.Competing interests None.References1. Schmidt M, Brechot N, Hariri S, Guiguet M, Luyt CE, Makri R, et al. Nosocomial Infections in Adult Cardiogenic Shock Patients Supported by Venoarterial Extracorporeal Membrane Oxygenation. Clin Infect Dis. 2012 Dec 15;55(12):1633–41.2. De Montmollin E, Bouadma L, Gault N, Mourvillier B, Mariotte E, Chemam S, et al. Predictors of insufficient amikacin peak concentration in critically ill patients receiving a 25 mg/kg total body weight regimen. Intensive Care Med. 2014 Jul;40(7):998–1005.O9 A high aminoglycoside regimen associated with renal replacement therapy for the treatment of multi-drug-resistant pathogensAlexandre Brasseur, Maya Hites, Sandrine Roisin, Frederic Cotton, Jean-Louis Vincent, Daniel De Backer, Frederique Jacobs & Fabio Silvio Taccone Soins Intensifs, Hôpital Erasme, Bruxelles, BelgiumAlexandre
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