33rd Congress of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine, Reykjavik, Iceland, 10 June 2015.

ACTA PRIZE ORAL PRESENTATIONS

Best Free Papers AP-01 Prevalence and outcome of gastrointestinal bleeding and use of acid suppressants in acutely ill adult intensive care patients Mette Krag1, Anders Perner1, Jørn Wetterslev2, Matt Wise3, Mark Borthwick4, Stepani Bendel5, Colin Mcarthur6, Deborah Cook7, Niklas Nielsen8, Paolo Pelosi9, Frederik Keus10, Anne Berit Guttormsen11, Alma D Moller12, Morten Hylander Møller1 1 Copenhagen University Hospital, Rigshospitalet, Denmark, 2 Copenhagen Trial Unit, Centre for Clinical Intervention Research, Denmark, 3Department of Adult Critical Care, University Hospital of Wales, United Kingdom, 4Pharmacy Department, Oxford University Hospitals NHS Trust, United Kingdom, 5Department of Intensive Care Medicine, Kuopio University Hospital, Finland, 6Department of Critical Care Medicine, Auckland City Hospital, New Zealand, 7Department of Medicine, McMaster University, Canada, 8Department of Anaesthesiology and Intensive Care, Helsingborg Hospital, Sweden, 9 Department of Surgical Sciences and Integrated Diagnostics, IRCCS San Martino, Italy, 10University of Groningen, Department of Critical Care, University Medical Center, Netherland, 11Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Norway, 12Department of Anaesthesia and Intensive Care, Landspitali, Iceland Purpose: To describe the prevalence of, risk factors for, and prognostic importance of gastrointestinal (GI) bleeding and use of acid suppressants in acutely ill adult intensive care patients. Methods: We included adults without GI bleeding who were acutely admitted to the intensive care unit (ICU) during a 7-day period. The primary outcome was clinically important GI bleeding in ICU, and the analyses included estimations of baseline risk factors and potential associations with 90-day mortality. Results: A total of 1034 patients in 97 ICUs in 11 countries were included. Clinically important GI bleeding occurred in 2.6% (95% confidence interval 1.6–3.6%) of patients. The following variables at ICU admission were independently associated with clinically important GI bleeding: 3 or more co-existing diseases (odds ratio 8.9, 2.7–28.8), co-existing liver disease (7.6, 3.3–17.6), use of renal replacement therapy (6.9, 2.7–17.5), co-existing coagulopathy (5.2, 2.3–11.8), acute (4.2, 1.7–10.2), use of acid suppressants (3.6, 1.3– 10.2), and higher organ failure score (1.4, 1.2–1.5). In ICU, 73% (71–76%) of patients received acid suppressants; most received proton pump inhibitors. In patients with clinically important GI bleeding, crude and adjusted odds for mortality were 3.7 (1.7–8.0) and 1.7 (0.7–4.3), respectively. Conclusions: In ICU patients clinically important GI bleeding is rare, and acid suppressants are frequently used. Co-existing diseases, liver failure, coagulopathy, and organ failures are the main risk factors for GI bleeding. Clinically important GI bleeding may be associated with 90-day mortality, but confounding explains some of this association.

Source: https://www.eventure-online.com/parthen-uploads/154/S SAI/img1_261980_UazbduVN8k.png

AP-02 Familiarity and genetic risk factors of acute kidney injury Martin Ingi Sigurdsson1, Snaevar Sigurdsson2, Thorir Einarson Long3, Olafur Skuli Indridason3,4, Gisli Heimir Sigurdsson3,5 1 Brigham and Women’s Hospital/Harvard Medical School, United States of America, 2DeCode Genetics, Iceland, 3faculty of Medicine, University of Iceland, Iceland, 4Division of Nephrology, Landspitali University Hopital, Iceland, 5Department of Anesthesia and Intensive Care, Landspitali University Hospital, Iceland Introduction: Acute Kidney Injury (AKI) is associated with high mortality and morbidity. We utilized an unique genealogy database and extensive genotyping on the Icelandic population to study the familiarity of AKI and perform a genome-wide association study (GWAS) to identify risk alleles for AKI. Methods: We reviewed all serum creatinine (SCr) measurements at Landspitali University Hospital serving the vast majority of Icelandic population over 20 years. For every individual with available SCr measurements, we identified the highest SCr value. a baseline SCr within the preceding 6 months and defined AKI as highest/ baseline SCr > 1.5. We excluded patients with disease known to cause AKI. We estimated familiarity comparing the risk of AKI in 1–5th degree relatives of AKI patients compared to 1000 random populations. We performed a case-control GWAS of AKI, using either measured or imputed genotypes. Results: A total of 12.807 individuals had AKI. There was a significant familiarity signal, with 1st-degree relative risk ratio (RR) of 1.21 2nd-degree relative RR of 1.08, 3rd-degree relative RR of 1.12 (P < 0.001 for all). The signal was stronger for the most severe AKI (highest/baseline SCR>3.0), where 1st-degree relative RR was 1.26 (P = 0.006), 2nd-degree relative RR was 1.12 (P = 0.067) and 3rd-degree relative RR was 1.11 (P = 0.06). The GWAS identified

© 2015 The Authors. Acta Anaesthesiologica Scandinavica © The Acta Anaesthesiologica Scandinavica Foundation Acta Anaesthesiologica Scandinavica, 59 (Suppl. 121), 1–60

2 several loci that reached genome-wide significant association with AKI. Conclusions: We have established a signal of familiarity of AKI indicating genetic contribution to its pathogenesis. Furthermore we identified several loci with strong association with AKI adjacent to biologically plausible genes, currently undergoing confirmation in independent cohorts.

AP-03 Transversus abdominis plane block versus wound infiltration in caesarean section: a double-blind randomised controlled trial

Methods: The use of early NIV and invasive mechanical ventilation (InvV) was examined in patients admitted with respiratory failure to 70 ICUs during 2008–2014. Exclusions were age < 16 years, patients with COPD, and when oxygenation or ventilation support data were missing. The ratio of PaO2 to FiO2 (P/F) was used to group patients with mild (26.7–40.0 kPa), moderate (13.3–26.6 kPa) and severe (< 13.3 kPa) ARF. Survival was analyzed using a multivariable Cox model after stratification by P/F ratio and adjusting for hospital category, age, comorbidities and derangements in acute physiology (except P/F ratio) as defined in Table 1 Source: https://www.eventure-online.com/parthen-uploads/154/SSAI/ img1_264369_fyTYZNs1w9.jpg.

Aage Telnes, Eirik Skogvoll, Herman Lonnee St.Olav0 s Hospital, Norway

Introduction: Multiple studies suggest that TAP block (without intrathecal morphine) after caesarean section reduces postoperative morphine consumption. In our study we wanted to compare the analgesic effect of TAP block with infiltration of the wound after caesarean section. Methods: We included sixty pregnant women scheduled for elective caesarean section under spinal anaesthesia in a randomised, single-centre, double-blind study. Thirty patients received ultrasoundguided TAP-block using 20 ml bupivacaine 0.25% with adrenaline 5 lg/ml bilaterally and 20 ml normal saline as wound infiltration (TAP group). The other thirty patients (the control group) received normal saline 20 ml bilaterally in the transversus abdominis plane, and 20 ml bupivacaine 0.25% with adrenaline 5 lg/ml as wound infiltration. The main outcome was cumulative morphine consumption at 48 h after surgery. In addition, continuous morphine consumption, pain scores and side effects were registered. Results: Fifty-seven patients completed the study. Cumulative morphine consumption at 48 h (mean SD) was 41 34 mg in the TAP group, and 38 27 mg in the control group (P = 0.7); a difference of 3 mg (95% CI 13 to 19 mg). Morphine consumption at any time up to 48 h was virtually identical in both groups. Side effects were similar, except for a higher degree of sedation in the TAP group (P = 0.04). Conclusion: Compared to wound infiltration with local anaesthetics, transversus abdominis plane block did not reduce cumulative morphine consumption following caesarean section. The TAP block was associated with more pronounced sedation.

AP-04 The effect of non-invasive ventilation on longterm survival in acute hypoxemic respiratory failure. An observational study of 12,428 patients stratified by the Berlin definition gas exchange criteria Sten Walther1, Apostolos Genaridis2, Johan Berkius3, Carl-Johan Wickerts4 1 Heart Centre, Sweden, 2S€odersjukhuset, Sweden, 3V€asterviks sjukhus, Sweden, 4Swedish Intensive Care Registry, Sweden Introduction: Noninvasive positive pressure ventilation (NIV) has become a standard therapy for the treatment of respiratory failure in chronic obstructive pulmonary disease (COPD), while the increasing early use in patients with hypoxemic acute respiratory failure (ARF) is controversial. The aim of the present study was to examine the influence of NIV and particularly when NIV was followed by invasive ventilation (NIV+InvV) in hypoxic ARF.

the SAPS3 model. Results: NIV was the initial mode in 48.7% of pts. with hypoxemic ARF. NIV only and NIV+InvV were associated with increased mortality compared to invasive ventilation only (Table). Conclusion: The use of early NIV in hypoxemic ARF was high. NIV was associated with increased mortality which may be explained by residual confounding (i.e. presence/absence of care limitations), although the finding with NIV+InvV is of concern. Early NIV must be used with care in hypoxemic ARF until proper studies have identified patients who truly benefit from NIV.

AP-05 Multidisciplinary team training reduces the emergency caesarean section decision-todelivery interval Lone Fuhrmann, Tina Heidi Pedersen, Anders Atke, Ann Merete Møller, Doris Østergaard Herlev Hospital, Denmark Introduction: In an emergency caesarean section (ECS), the life of the pregnant woman and/or the foetus is at risk. A 30-min standard for the decision-to-delivery interval (DDI) is common practice and supported by national organisations including The Danish Society for Obstetrics and Gynaecology. Danish obstetric departments report the DDI to a national database. Acceptable performance is when 95 per cent of ECSs are achieved within the timeframe. In our hospital 34.4 per cent of ECSs met the 30-min standard in 2011. This study aims to evaluate the effect of a simulation-based team training program. The effect was measured on the DDI. Method: An interventional before-and-after study was performed. A total of 100 30-min ECSs before the intervention (team training) and afterward, were evaluated. The primary outcome was the percentage of 30-min ECSs that met the standard. Results: A total of 20 team training courses were held in May/ June 2013 to train 239 of 252 team members (36 obstetricians, 45 scrub nurses, 83 midwifes, 38 anaesthesiologists, 37 nurse anaesthetists). This corresponds to 95% of staff. The number of 30-min ECSs that met the standard was significantly higher after team training (84/96, 87.5 per cent, CI 76.7–91.3) compared to before (71/96, 74 per cent, CI 62.0–80.1) (P = 0.017). Conclusion: Team training can increase the percentage of 30-min ECSs with a DDI within 30 min. Using a national clinical database


3 for evaluating team training establishes a link between the team training and the clinic and team performance can be followed over time.

ole (400 mg twice daily on the first day and 200 mg twice for 4 days). Plasma and urine concentrations of buprenorphine and norbuprenorphine were determined up to 18 h. Pharmacokinetic parameters were calculated using standard noncompartmental methods.

AP-06 Prehospital lung ultrasound for the diagnosis of cardiogenic pulmonary oedema: a pilot study

Table Values are normalised for a oral dose of 1.0 mg. Source: https:// www.eventure-online.com/parthen-uploads/154/SSAI/img1_264587_sYWzV56qwG.jpg

Henrik Karsten Berg, Stefan Posth, Anja H€anselmann, Christian Borbjerg Laursen Odense University Hospital, Denmark

Background: An improved prehospital diagnostic accuracy of cardiogenic pulmonary oedema could potentially improve initial treatment, triage and outcome. Several in-hospital studies have documented the use of lung ultrasound for the diagnosis of cardiogenic pulmonary oedema. A pilot study was conducted to assess the feasibility, time-use and diagnostic accuracy of prehospital lung ultrasound (PLUS) for the diagnosis of cardiogenic pulmonary oedema in patients with signs of respiratory failure. Methods: A prospective observational study was conducted in a prehospital setting. Patients were included if the physician based prehospital emergency service was activated and one or more of the following two were present: respiratory rate > 30/min, oxygen saturation < 90%. Following clinical assessment PLUS was performed and presence or absence of interstitial syndrome was registered. Audit by three physicians using predefined diagnostic criteria for cardiogenic pulmonary oedema was used as golden standard. Results: A total of 40 patients were included. Feasibility of PLUS was 100% and median time used for PLUS was 3 min (IQR 2– 4 min). The gold standard diagnosed 18 (45.0%) patients with cardiogenic pulmonary oedema. The diagnostic accuracy of PLUS for the diagnosis of cardiogenic pulmonary oedema was: sensitivity 94.4% (95% CI 72.7–99.9%), specificity 77.3% (95% CI 54.6–92.2%), PPV 77.3% (95% CI 54.6–92.2%), NPV 94.4% (95% CI 72.7–99.9%). Conclusion: Performed as a part of a physician based prehospital emergency service, PLUS seems fast and highly feasible in patients with respiratory symptoms. Due to its diagnostic accuracy, PLUS has potential as a prehospital tool, especially to rule out cardiogenic pulmonary oedema.

Free Paper Session 1 – Pain Medicine O1-01 Effect of voriconazole on the pharmacokinetics of oral buprenorphine

Mari Kaarina Fihlman1, Tuija Hemmil€a1, Nora Hagelberg1, Kari Laine1, Pertti Neuvonen2, Klaus Olkkola2, Teijo Sari1 1 University of Turku, Finland, 2University of Helsinki, Finland Introduction: Buprenorphine is used in low doses in the treatment of moderate acute and chronic pain and in high doses in the management of opioid withdrawal symptoms and opioid addiction. Buprenorphine undergoes extensive first-pass metabolism and has an oral bioavailability of 15% only.1 Because buprenorphine is metabolised extensively by cytochrome P450 (CYP) 3A enzymes, we found it important to study its possible interaction with voriconazole, strong inhibitor of CYP3A enzymes. Patients and methods: We used arandomized crossover, two-phase, placebo-controlled study design at intervals of 4 weeks in 12 healthy volunteers. The volunteers were given 3.6 mg oral buprenorphine after placebo (control) and 0.2 mg after oral voriconaz-

Results: The peak plasma concentration of buprenorphine increased by 400% after voriconazole. Voriconazole increased the exposure to oral buprenorphine by 270% as judged by the value for AUC0-18. Results are summarized in the Table. Conclusion: Voriconazole increases the peak exposure to buprenorphine. Clinicians should be aware that voriconazole may increase and prolong the pharmacological action of buprenorphine. Reference: [1] Cone EJ et al. The metabolism and excretion of buprenorphine in humans. Drug Metab Disp 1984; 12: 577–81.

O1-02 Preoperative dexamethasone in combination with perioperative paracetamol and ibuprofen reduces pain after lumbar disc surgery: a randomized, blinded, placebo-controlled trial Rikke Vibeke Nielsen1, Hanna Siegel1, Jonna Storm Fomsgaard1, Johnny Dohn Holmgren Andersen2, Robert Martusevicius1, Ole Mathiesen3, Jørgen Berg Dahl4 1 Glostrup University Hospital, Denmark, 2Herlev University Hospital, Denmark, 3Koege University Hospital, Denmark, 4Bispebjerg University Hospital, Denmark Background: Combinations of different non-opioid analgesics may enhance pain relief due to additive or synergistic effects of the combinations, and reduce opioid requirements and opioid-related adverse effects.We investigated the effect of preoperative dexamethasone in combination with perioperative paracetamol and ibuprofen on pain and opioid requirements after lumbar disc surgery. Methods: 160 patients were randomly assigned to either group A (placebo) or group B (16 mg dexamethasone i.v) in this blinded study of patients undergoing lumbar disc surgery in general anaesthesia. All patients received perioperative paracetamol and ibuprofen, and postoperative i.v. PCA morphine. The primary outcome was pain during mobilization [visual analogue scale (VAS)] 2–24 h postoperatively. Secondary outcomes were pain at rest, opioid consumption, nausea, vomiting, consumption of ondansetron, sedation, and quality of sleep. Patients were followed up with a written questionnaire 90 days after surgery. Results: Pain during mobilization (area under the curve, 2–24 h) was significantly reduced in the dexamethasone group: 33 (22) mm vs placebo 43 (18) mm, (95% CI 2.9–16.4) P = 0.005. Vomiting 0–24 h postoperatively was reduced in the dexamethasone group vs placebo (P = 0.006). No other differences were observed between groups. No differences between groups in pain, surgical-, or drug-related complications were observed at follow-up 90 days after surgery.


4 Conclusion: Preoperative dexamethasone in combination with a basic analgesic regimen of paracetamol and NSAID significantly reduced pain during mobilisation and vomiting 2–24 h after lumbar disc surgery.

patients without impairing patients’ response to the intraoperative stimulation test.

O1-04 The area of secondary hyperalgesia characterizes healthy volunteers Morten Sejer Hansen1, Jørn Wetterslev2, Christian Bressen Pipper3, Mohammad Sohail Asghar4, Jørgen Berg Dahl5 1 Rigshospitalet, Denmark, 2Copenhagen Trial Unit, Centre for Clinical Intervention Research, dep. 7812, Denmark, 3Section of Biostatistics, Faculty of Health, Copenhagen University, Denmark, 4Department of Anaesthesiology, 4231, Rigshospitalet, Denmark, 5Department of Anaesthesiology, Bispebjerg and Frederiksberg Hospitals, Denmark

Fig. 1. Pain scores (VAS) during mobilization 2–48 h after operation. Source: https://www.eventure-online.com/parthen-uploads/ 154/SSAI/img1_264141_NypUmB1vds.jpg

O1-03 Epidural anesthesia for permanent spinal cord stimulation with a linear type lead Jaedo Lee, Rockmin Choi, Rim Gi VHS medical center, South-Korea Background: Spinal cord stimulation (SCS) is performed for trial with external stimulation, and then permanent implantation for those who find it effective. The trials could be easily conducted under local anesthesia. However, permanent SCS implantation is very painful, even intolerable in some patients. Epidural anesthesia can be used to perform the SCS implantation without discomfort if the patient can localize the area of parethesia. However, little is known about epidural anesthesia for SCS with a linear type lead. Methods: Twenty-five patients, who were implanted permanent SCS under epidural anesthesia at one institution between November 2010 and December 2013, were retrospectively enrolled. Epidural anesthesia was induced at the L2-L3, L3-L4 or L4-L5 level. Anesthetic level and complications were recorded. SCS parameters were compared in the trial (T0), permanent implant (T1) and postoperative stimulation 3 days after surgery (T2). Results: Epidural anesthesia was sufficient to perform the implantation of the lead and generator in 24 patients without discomfort and significant complication. Only one patient experienced incomplete epidural anesthesia and required additional analgesics due to pain. The highest level of the sensory block was fourth thoracic segment (8.0%) and the lowest level was tenth thoracic segment (4.0%). All the leads were placed consistent with the patient’s report of paresthesia area under epidural anesthesia. Conclusions: Epidural anesthesia is an effective and safe method for the optimal placement of SCS to minimize the discomfort for

Introduction: Experimental pain models can be applied when investigating basic physiologic pain responses in healthy volunteers. Several experimental pain models exist; however, only few have been adequately validated. Our primary aim with this prospective study was to investigate the intra- and inter-individual variation in experimentally elicited secondary hyperalgesia by Brief Thermal Sensitization – a heat injury experimental pain model. In addition we also performed an evaluation of the model’s applicability in healthy volunteers. Methods: Fifty healthy volunteers were included. Areas of secondary hyperalgesia following Brief Thermal Sensitization were investigated by 2 observers on 4 experimental days, with a minimum interval of 7 days. Additionally, the experimental pain models Heat Pain Detection Threshold and Long Thermal Stimulation, and the psychological tests Pain Catastrophizing Scale and Hospital Anxiety and Depression Score were applied. Results: An intra-observer intra-person correlation of 0.85, 95% CI [0.78–0.90], an intra-observer inter-person correlation of 0.03 [0.00– 0.16], and a coefficient of variation of 0.17 [0.14–0.21] was demonstrated. Only two, 4% [1%, 13%], of all study participants had areas of secondary hyperalgesia both below the 1st and above the 3rd quartile. Heat Pain Detection Threshold predicted area of secondary hyperalgesia with an adjusted R2 of 0.20 (P = 0.0006). Conclusions: We have demonstrated a low intra-individual, and a high inter-individual variation. We conclude that the experimental pain model Brief Thermal Sensitization produce secondary hyperalgesia with a high level of reproducibility, which can be applied to investigate different phenotypes related to secondary hyperalgesia in healthy volunteers.

O1-05 Cervical myelopathy associated with paravertebral neck muscle rhabdomyolysis following buprenorphine abuse Tuukka Jussi Puolakka1, Jari Honkaniemi2, Matti Vuorialho3, Pinne V€a€an€anen4 1 Helsinki University Hospital, Finland, 2Hatanp€a€a Hospital, Finland, 3 Vaasa Central Hospital, Finland, 4Kuopio University Hospital, Finland Introduction: Buprenorphine is a semi-synthetic opioid with antiantagonistic properties. Although it is widely abused in Scandinavia and other settings worldwide, few reports have discussed the severe complications associated with buprenorphine abuse. Methods: We describe six patients treated in three Finnish hospitals during 2009–2012 who suffered from extensive cervical mye-


5 lopathy and rhabdomyolysis of deep neck muscles following an episode of buprenorphine abuse. Results: All six patients were young males (age 16–21 years) with a history of drug abuse. Approximately 24–48 h before hospital admission they had taken a dose of buprenorphine with pregabalin and/or benzodiazepines. The buprenorphine was administered intravenously in five cases and intranasally in one case. All patients reported passing out soon after taking the drugs. After waking up several hours later they had difficulties in moving their extremities and they sought medical care. In the emergency department, a varying degree of tetraparesis was seen without any signs or anamnesis of trauma. Cerebrospinal fluid analysis was unremarkable. The following MRI revealed an extensive myelopathy lesion in the cervical spinal cord and extensive rhabdomyolysis in the paravertebral deep neck muscles. Conclusions: Myelopathy has been previously associated with heroin use but never with a synthetic opioid. Rhabdomyolysis of the neck muscles is likewise an uncommon phenomenon. Since the patients’ superficial neck muscles were spared, we suspect that the rhabdomyolysis was the result of a cervical compartment syndrome. As the MRI findings in the muscles and spinal cord were adjacent to each other, we suggest a common mechanism causing the lesions.

O1-06 Support of acute pain therapy by Analgesia Nociception Index (ANI) in Postanesthesia Care Unit (PACU)

Nadine Hochhausen1, Monica Ritter2, Marcus Ko€ny3, Rolf Rossaint1, Michael Czaplik1 1 University Hospital RWTH Aachen, Germany, 2Department of Anaesthesiology, Germany, 3RWTH Aachen University, Germany

Introduction: Postoperative pain is harmful and inconvenient for patients. Furthermore, acute pain has negative effects on physical recovery and may become chronic. Therefore, a well-directed postoperative pain therapy is essential. Usually, pain therapy is directed by patient’s self-evaluation, using a numeric rating scale (NRS, 0– 10). Recently, a new „pain monitor”was introduced. Based on heart rate variability, the so-called ANI is calculated representing different pain levels. The aim of this study was to investigate whether continuous pain monitoring using ANI is capable to improve postoperative acute pain therapy. Therefore, mean NRS was considered as primary outcome parameter among several secondary parameters. Methods: Postoperative patients (n = 56) were randomly assigned to intervention (IN) or control group (CO) after admission to the PACU. Treatment and monitoring were performed according to internal hospital standards. Analgesia was achieved in both groups when NRS exceeded 4 during a routine evaluation or in between. In control group, pain intensity was assessed by NRS every 15 min. In intervention group, patients were additionally addressed when ANI fell below a preassigned level. Results: No differences were found between IN and CO regarding mean NRS. Overall correlation between ANI and NRS was low. However, considering patient-individual ANI thresholds rather than uniform ones can significantly improve sensitivity and specificity. Conclusion: Objective monitoring of pain intensity particularly in awake patients remains challenging. Potentially, a preoperative set individual ANI baseline value could improve feasibility.

Free Paper Session 2 – Monitoring O2-01 A study aimed at determining the most reliable of five algorithms that calculate cardiac output from the arterial waveform Lester Augustus Hall Critchley1, Jie Zhang1, Li Huang2 1 The Chinese University of Hong Kong, Hong Kong, 2Peking University First Hospital, China Introduction: Different mathematical approaches are used to calculate arterial pulse pressure wave analysis (PPWA) cardiac output (CO). The CardioQ-Combi is a research oesophageal Doppler (COODM) monitor that includes five fundamental PPWA algorithms. We compared these PPWA CO readings to COODM and suprasternal USCOM Doppler (COUS) over a range of CO values induced by dopamine infusion in patients undergoing major surgery. Methods: Serial sets of CO data were recorded at regular intervals as CO increased. Formulae included: CO calculated form systemic vascular resistance, pulse pressure (e.g. FloTrac-Vigileo), LiljestrandZander formula (COLZ), alternating current power (LiDCO) and systolic area (PiCCO). The reference method for comparisons was COODM. Statistical methods included: Group correlation, Bland-Altman and concordance trend analysis. Acceptable Bland-Altman percentage error was < 30% and concordance rate was > 92%. Results: From 21 patients 263 set of CO comparative data were collected. Mean CO from the Doppler and PPWA methods ranged between 5.0 and 5.5 l/min. The correlation between COODM and COUS was R2 = 0.81, which was greater than that for the five PPWA algorithms that were R2 = 0.53 to 0.72. Of these COLZ was best. Bias was 0.1 and 0.5 l/min. COUS percentage error was 27.4%, COLZ was 35.6%, and other PPWA algorithms were 41.0 to 55.6%. Concordance rate for COUS was 92% and PPWA algorithms 63.8–72% with COLZ being highest. Conclusions: Accept for the Doppler method USCOM, the Liljestrand-Zander PPWA formula was most reliable compared to oesophageal Doppler in major surgical patients and is used in the new CardioQ-ODM+.

Table 1 Agreement between PVI and Doppler whether a fluid bolus was indicated according to the respective algorithm. Table 1. Correlation, Bland-Altman and concordance analysis of USCOM and the five PPWA algorithms against oesophageal Doppler. Source: https://www.eventure-online.com/parthen-uploads/154/SSAI/ img1_258013_L7iDAgFMv9.jpg.

O2-02 How to fail at a clinical trial - a terminated randomized controlled trial Ib Jammer1, Mari Tuovila2, Atle Ulvik1, Gro Østgaard1 1 Haukeland University Hospital, Norway, 2Oulun University Hospital, Finland


16 O5-04 Comparison of the success of two techniques for the endotracheal intubation with C-Mac videolaryngoscope straight blade in paediatric patients: a randomized study Renu Sinha, Ankur Sharma, Bikash Ranjan Ray, Ravinder Kumar Pandey, Vanlal Darlong, C. Chandralekha All India Institute of Medical Sciences, India Introduction: C-Mac video laryngoscope (Karl Storz endoscopy, Tuttlingen, Germany) with standard pediatric sized blades is a newly available technology with limited case reports experience. Ease of endotracheal intubation for C-Mac staright blade has not been evaluated. Method: Sixty children of either sex weighing 3–15 kg with normal airway for surgery under general anesthesia requiring endotracheal intubation were included. C-MAC straight blade was inserted thorough midline and epiglottis was lifted to visualize the glottis. Endotracheal intubation was attempted with or without styleted ETT according to the randomized group (group S or group WS). Time to intubation and total time for the procedure was recorded. Number of attempts, any reposition of blade and any maneuvers to ease intubation was also noted. Any desaturation, bradycardia and other complications were recorded. Results: Age varied from 3 months to 6 years. Weight of the children ranges from 2.1–15 kg, time to intubation in group S varied from 8 to 55 s and in group WS from 9-60 seconds. In group S no second attempt was required for intubation in comparison to group WS where second attempt was needed in two children. Conclusions: There is o statistical difference in time to intubate with styleted and without styleted ETT with C-Mac straight blade size 0 and 1 in children weighing upto 15 kg. Delay in intubation is more due to small epiglottis and due to slippage of tongue on the right side of the blade thus obstruction the view and decreasing the space.to negotiate the ETT.

O5-05 AirQ intubating laryngeal mask airway as a conduit for blind orotracheal intubation in children: ‘an interventional clinical trial’ Ravinder Kumar Pandey, Rajkumar S, Jyotsna Punj, Vanlal Darlong, Chandralekha, Minu Bajpai, Vimi Rewari All India Institute of Medical Sciences, India Introduction: In low resource settings, management of difficult pediatric airway is really challenging due to limited options, especially unavailability of FOB. Therefore in such remote places blind endotracheal intubation (ETI) using intubating LMA as a conduit is a good option. Methods: After IEC approval 60 ASA grade I & II children were enrolled. In all children, after standard premedication and anaesthesia technique, an appropriate sized AirQILA was placed. Patient’s glottis view was assessed by FOB (through AirQILA) in both positions. However, the trachea was intubated blindly in supine position by passing appropriate sized endotracheal tube (ET) through AirQ ILA. Parameters assessed were number of attempts of AirQILA and ET placement, glottis view, perioperative airway complications, and time for AirQILA and ET placement. Results: Most of our study population was male, weight < 15 kg. Grade I glottic view was the commonest. Success rate of blind ETI was 83.37% in two attempts. However in 16.67% patients, blind ETI was failed. The mean time for successful AirQILA and ET placement were 16.64 s and 20.57 s. respectively. Success rate for

blind ETI was higher in children < 15 kg (P = 0.021). Overall, desaturation, trauma and ET displacement during removal of Air QILA occurred in1.7%, 1.6% and 3.3% respectively. Conclusion: AirQ ILA is a user friendly, safe, easy to place SGD with an excellent airway seal and low airway morbidity in pediatric population. It is particularly useful as a conduit for blind ETI in supine position, and may be an effective alternative to FOB in low resource settings.

O5-06 Thromboelastometry detects impaired platelet aggregation during but not after paediatric cardiac surgery

Birgitta, Sofia Romlin1, Fredrik So€derlund1, Anders Jeppsson2 1 Queen Silvia Childrens Hospital, Sahlgrenska University Hospital, Sweden, 2Department of Molecular and Clinical Medicin, Sahlgrenska Academy, University of, Sweden Background & Aim: Low platelet count and/or impaired platelet function increases the risk of bleeding complications in cardiac surgery. Reliable detection of impaired platelet function may improve treatment. We investigated whether thromboelastometry detects clinically significant perioperative ADP-dependent platelet dysfunction. Methods: Fifty-seven paediatric cardiac surgery patients were included in a prospective observational study. Modified rotational thromboelastometry (with heparinase) and multiple electrode platelet aggregometry were analyzed at five time points before, during, and after surgery.The accuracy of thromboelastometric indices of platelet function (maximum clot firmness (MCF) and clot formation time (CFT), to detect ADP-dependent platelet dysfunction (defined as ADP-induced aggregation of £30 units) was calculated with receiver operating characteristics (ROC) analysis, which also was used to identify optimal cut-off levels. Positive and negative predictive values for the identified cut-off levels to detect platelet dysfunction were determined. Results: MCF and CFT had a high accuracy to predict platelet dysfunction during cardiopulmonary bypass (area under the ROC curve 0.89 and 0.83 respectively, both P < 0.001) but not immediately after CPB (0.64 and 0.67, or at arrival to ICU (0.53 and 0.60). Optimal cut-off levels were MCF < 43 mm and CFT > 166 s. The positive and negative predictive value were high during cardiopulmonary bypass (87% and 67% respectively for MCF > 43 mm; 80% and 100% for CFT > 166 s) but markedly lower after surgery. Conclusion: In paediatric cardiac surgery, thromboelastometry has acceptable ability to detect ADP-dependent platelet dysfunction during but not after cardiopulmonary bypass.

Free Paper Session 6 - Pain Medicine/Orthopedic Anaesthesia O6-01 Treatment and outcome of patients with hip fracture Kristofer Arnar Magnusson1, Gisli Heimir Sigurdsson1,2, Yngvi Olafsson3, Brynjolfur Mogensen1,4, Sigurbergur Karason1,2 1 University of Iceland, Iceland, 2University of Anesthesia and Intensive Care, 3Department of Orthopedics, 4department of Emergency Medicine, Landspitali National University Hospital, Iceland Introduction: Hip fractures are common amongst the elderly and are associated with increased mortality. The aim of this study was to describe treatment and outcome in patients suffering a hip fracture.


7 O2-05 Influence of planecta with three-way stopcock for the natural frequency of blood pressuretransducer kits Keiichi Tachihara1, Shigeki Fujiwara1, Satoshi Mori1, Takashi Hitisugi1, Izumi Toyoguchi2, Takeshi Yokoyama1 1 Kyushu University, Japan, 2Argon Medical Devices, Japan Introduction: Flat type planecta (FTP) and planecta with three-way stopcock (PTS) are often used for the blood pressure-transducer kit. We reported that insertion of FTP decreased the natural frequency of the kit. In the present study, we investigated influence of PTS on the natural frequency of the kit in comparison with the kit with FTP. Methods: DT4812J (Argon Medical Devices, TX, USA) was prepared with FTP or PTS, and the effects of FTP or PTS on the frequency characteristics were examined. The natural frequency and damping coefficient of the kit were obtained using frequency characteristics analysis software, and evaluated by plotting them on the Gardner’s chart. Results: The natural frequency markedly decreased in the kit by insertion of two FTPs from 42.5 Hz to 28.1 Hz. The frequency characteristics of the kit showed underdamping on the Gardner’s chart. On the other hand, the natural frequency slightly decreased by insertion of two PTSs from 42.5 Hz to 41.3 Hz. The frequency characteristics of the kit were adequate for pressure monitoring. Discussion: Two or more FTPs should not be inserted in the pressure transducer kit, since they decrease the natural frequency markedly and make the kit underdamp. However, insertion of PTS is less effective on the frequency characteristics of the kit. In conclusions, we recommend insertion of PTS when two or more planectas were required for the blood pressure-transducer kits.

O2-06 Modified capnodynamic method for continuous assessment of effective pulmonary blood flow

Caroline H€ allsj€ o Sander1, Thorir Sigmundsson1, Magnus Hallb€ack2, akan Bj€orne1 Mats Wallin2, Anders Oldner1, H 1 Karolinska University Hospital Solna, Sweden, 2Maquet Critical Care AB, Sweden Introduction: A capnodynamic equation can be used to calculate effective pulmonary blood flow (COEPBF) i.e. cardiac output minus shunt. The method could be integrated into a standard ventilator and provide a continuous non-invasive alternative for estimation of COEPBF in intubated mechanically ventilated patients. The aim of the current study was to evaluate if the performance of COEPBF was improved by a modified breathing pattern. Methods: Alterations of alveolar concentration of carbon dioxide are a prerequisite to solve the capnodynamic equation and can be accomplished by a predefined ventilatory pattern including sequences of three breaths with an expiratory hold followed by six normal breaths. COEPBF was compared to a reference method for cardiac output, an ultrasonic flow probe around truncus pulmonalis (COTS), in a porcine model (N = 8). The circulation was altered including preload reduction, controlled bleeding and inotropic stimulation as well as changes in respiratory conditions with varied PEEP levels and increased tidal volumes. Agreement and trending ability was evaluated using Bland-Altman statsitics and four-quadrant plot methodology. Results: The overall agreement for all interventions was good with bias, limits of agreement (LoA) and percentage error 0.05,

(1.1 to 1.2) l/min and 36%. The trending ability was good with a concordance rate of 98%. Discussion: COEPBF with a modified breathing pattern based on expiratory holds showed improved overall agreement in absolute values compared to our previous animal studies with a ventilatory pattern based on inspiratory holds. Trending ability was preserved for all hemodynamic and respiratory interventions. Fig. 1. Eventline for all interventions and cardiac output displayed by the novel method (COEPBF) and the reference method for cardiac output (COTS). Source: https://www.eventure-online.com/ parthen-uploads/154/SSAI/img1_265082_CRd7fwoatk.jpg

O2-07 Passive leg raise (PLR) response in normotensive elderly patients and the effects of subdural block - maesured by LiDCOplusTM and transthoracic echocardiography (TTE)

Marcus Brynjolf1, Erzsebet Bartha1, Sigridur Helga Kalman2 1 Karolinska Institutet, Sweden, 2Karolinska University Hospital Huddinge, Sweden

Introduction: We have found that maximization of stroke volume (SV) by fluid challenge, the first step of Goal Directed Haemodynamic Treatment, at high age reduce the SVI in a majority of patients.1 A reversible fluid challenge, a “self-volume loading”(PLR) might be helpful. The interpretation and the relevance of positive PLR response in normotensive patients2 in per-operative clinical scenarios are unclear. A study with two aims: to assess the ability of LiDCOplus[TRADEMARK] to follow SV variations following PLR; and to describe the hemodynamic responses to subdural block in PLR responders/non-responders. Methods: Design: observational pilot study (ethical ID: 2013/99531/3). Patients: patients > 80 years scheduled for urologic elective in spinal anesthesia with informed consent. Monitors: The SV measurements were performed by LiDCOplus[TRADEMARK] (calibrated two times) and TTE. Results: Ten patients, mean age 84 years were enrolled. Paired readings of SVI was compared in Bland-Altman analysis. Trending ability and concordance of LiDCOplus[TRADEMARK] will be illustrated by four quadrate plot3. Echocardiography is the reference method and concordance rates >90% shall support good ability4. The percental changes of hemodynamic parameters and the frequency of hypotension after subdural block in PLR responders/ non-responders shall be given.


8 Conclusions: Our data may supprt design of future trials addressing the value of PLR to discriminate patients with particular responses to spinal block. References: [1] Bartha E. Br J Anaesth 2013; 110: 545–53. [2] Monnet X. Curr Opin Crit Care 2007; 13: 549–53. [3] Critchley LA. J Cardiothorac Vasc Anesthesia 2013; 27: 1122–7. [4] Pugsley J. J Cardiothorac Vasc Anesth 2010; 14: 274–82. Source: https://www.eventure-online.com/parthen-uploads/154/ SSAI/img1_265114_GZPh9yU04k.jpg

O2-09 Haemodynamic changes during spinal anaesthesia at high age Marcus Hellkvist, Sigridur Kalman, Erzse´bet Bartha Karolinska University Hospital, Sweden

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O2-08 Hemodynamic changes and spinal anaesthesia in elderly patients - why should we not pre-load with fluids? Julia Jakobsson, Sigridur Kalman, Marge Lindberg-Lindvet, Erzse´bet Bartha Karolinska University Hospital, Sweden Introduction: A comprehensive analysis of our randomized controlled trial (RCT) on per-operative goal directed haemodynamic treatment (GDHT) in patients with hip fracture,1 revealed unexpected haemodynamic patterns. In the routine group the preanaesthesia fluid loading failed to prevent the post spinal hypotension, decreased baseline stroke volume index (SVI), and at the end of surgery oxygen delivery index (DO2I) decreased in > 50% of patients. To explore these observations we ran a pilot study in younger orthopedic patients. We report the effects of pre-anaesthesia fluid loading and of spinal anaesthesia. Methods: Prospective, observational study (ethical approvement ID2010/2042-31/1). Patients mean 71(66–89) years, scheduled for orthopedic surgery; Interventions: Pre-anaesthesia fluid loading at the discretion of the attending anesthesiologist, and Buffered Glucose 25 mg/ml (1 ml/kg/h) and Ringer’s acetate (2 ml/kg/h); spinal anaesthesia. Monitoring: LiDCOplus[TRADEMARK] blinded to the anaesthesiologist. Hemodynamics was followed from baseline until 45 min after spinal anesthesia. Outcomes: percental changes of haemodynamic parameters after pre-anaesthesia fluid loading and spinal anaesthesia. Results: Two previous findings were reproduced: pre-loading failed to prevent post spinal hypotension1, 2 and a biphasic pattern of DO2I was seen after spinal anaesthesia.3 A new finding was that pre-loading reduced SVI in the majority of patients Conclusions: Preloading without signs of hypovolemia could be questioned. Studies are needed to assess the role of pre-emptive maximization of SVI in GDHTprotocols. References: [1] Bartha E. Br J Anaesth 2013; 110: 545–53. [2] Rooke GA. Anesth Analg 1997; 85: 99–105. [3]Meyhoff CS. Eur J Anaesthesiol 2007; 24: 770–5.

Introduction: During our randomized controlled trial (RCT) on per-operative Goal Directed Haemodynamic treatment in patients with hip fracture1 we observed that patients allocated to routine fluid care, reduced the oxygen delivery index (DO2I) during the whole observation time (end of surgery). The aim is to explore this reduction and to describe the patterns of haemodynamic changes the first 45 min after spinal anaesthesia in the routine care group. Methods: Design: post-hoc analyses of haemodynamic data obtained from a RCT.1 Population: Patients mean age 85 range 70– 101 anaesthetized by spinal anaesthesia. Treatment: Pre-anaesthesia fluid loading by 300-500 ml of Ringer’s acetate, and Buffered Glucose 25 mg/ml at 1 ml/kg/h and Ringer’s acetate 2 ml/kg/h; Monitoring: LiDCOplus[TRADEMARK], blinded to the attending anaesthesiologist. Data collection: LiDCOplus[TRADEMARK] and ICU pilot software. Missing values were intrapolated. Outcomes: haemodynamic parameters during 45 min after spinal anaesthesia. Categorical data are given by number, continuous data in median and range. *Hypotension: reduction of base line systolic blood pressure ≥ 30%. Results: Patient characteristics. ASA no 2/17/38/7, P-POSSUM 20 (19–21), pre-anaesthesia fluid loading (ml/kg) 1.2 (0–12), base line stroke volume index (ml/m2) 34 (12–103), and vasoactive treatment for hypotension* 47. Conclusion: A biphasic change of DO2I after spinal anaesthesia was seen in four clinical scenarios: normotension/hypotension/ and sedation/ non-sedation. These changes need further research extending into the postoperative period including measurements of oxygen consumption to provide rationale target values of DO2I in GDHT protocols. Reference: [1] Bartha E. Br J Anaesth 2013; 110: 545-53.

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40 O14-06 Prediction of survival in patients suspected of DIC using antithrombin, protein C, alpha-2antiplasmin, and ISTH score Einar Hjo¨rleifsson1, Gisli Heimir Sigurdsson1,2, Martin Ingi Sigurdsson2, 1,2 € Brynja R Gudmundsdottir3, Pall Torfi Onundarson 1 University of Iceland, School of Health Sciences, Iceland, 2Brigham and Women0 s Hospital, United States of America, 3Landspitali National University Hospital, Iceland Introduction: The purpose of this study was examine the association of antithrombin, protein C and alpha-2-antiplasmin with mortality in critically ill patients, both fulfilling and not fulfilling criteria for overt disseminated intravascular coagulation (DIC) set forth by the International Society of Thrombosis and Haemostasis (ISTH). Methods: All consecutive patients suspected of acute DIC over a 5 year period at a single tertiary care hospital were identified and scored according to overt ISTH criteria. The influence of ISTH score, antithrombin, protein C and antiplasmin measurements on mortality was assessed. Results: There were 1825 occurrences in 1814 patients, 92 with ISTH score ≥ 5. The 28-day mortality was 3, 11, 16, 23, 35 and 52% and the one year mortality was 5, 18, 24, 36, 54 and 63%, respectively for patients with an ISTH score of 0, 1, 2, 3, 4 and ≥ 5 (P < 0.001). Antithrombin and protein C correlated inversely with both the ISTH score (P < 0.001) and APACHE II score (P < 0.001). Antiplasmin decreased when the ISTH score was above 3. Both the 28 day and one-year mortality increased progressively as antithrombin and, in particular, protein C decreased. One-year survival was higher in those with the lowest antiplasmin. Conclusions: The study shows that mortality in patients suspected of acute DIC increases progressively across the spectrum of the overt ISTH score and not only in those fulfilling the ISTH overt DIC criteria. Furthermore, the measurement of protein C appears useful to assess mortality risk upfront in critically ill patients suspected of DIC.

O14-07 Effect of albumin and mannitol combination on thromboelastometry in vitro

€ Kirsim€agi2, Kadri Lillem€ ae1, Antti Laine1, Alexey Schramko1, Ulle 1 Tomi Tapio Niemi 1 University of Helsinki and Helsinki University Hospital, Finland, 2 Tartu University Hospital, Estonia

Introduction: Both albumin and mannitol may interfere with haemostasis but their co-influence on blood coagulation is partly unclear. We aimed to determine the co-effects of albumin and mannitol or Ringer acetate at various haemodilution levels on blood coagulation in randomized cross-over in vitro study. Methods: From citrated fresh whole blood, withdrawn from 10 volunteers, we prepared 2,5, 5, 10, 15 and 20 vol% dilutions of 4% albumin (Alb groups). Each sample was thereafter diluted by 15% mannitol (Alb/Man group) or Ringer acetate (Alb/RAC group) at a ratio of 9 : 1 (an additional 10 vol% dilution). Samples were analysed with thromboelastometry (ROTEMâ) using two activators, FibTEMâ or ExTEMâ. Results: In FibTEM analysis, maximum clot firmness (MCF) decreased more in Alb10/Man and Alb15/Man group than in corresponding dilution in Alb/RAC and Alb groups (P < 0.05). Using ExTEM, clot formation time (CFT) was delayed more in Alb5/ Man, Alb10/Man and Alb15/Man group than in corresponding dilution in Alb/RAC groups (P < 0.05). In Alb2,5/Man and Alb20/Man, CFT was delayed compared to Alb2,5 and Alb20

groups (P < 0.05), but it was not different to the delay seen in corresponding dilutions in Alb/RAC groups. Compared to Alb groups, MCF was weaker in all dilution levels after adding Mannitol or RAC (P < 0.05). In Alb groups, CFT was prolonged in 20 and MCF decreased in 10, 15 and 20 vol% dilution (P < 0.05). Conclusions: Albumin in combination with mannitol impairs haemostasis in vitro. Although it is partly caused by dilutional effects, the simultaneous administration of mannitol and albumin might aggravate bleeding. Table 1 Source: https://www.eventure-online.com/parthen-uploads/154/SSAI/ img1_262967_XB8m3GMzxz.jpg.

O14-08 Thromboelastometric (ROTEMⓇ) analyses show compromised hemostasis when performed at 33°C Anni Noergaard Jeppesen, Hans Kirkegaard, Susanne Ilkjær, Anne-Mette Hvas Aarhus University Hospital, Denmark Introduction: A compromised coagulation may be visualized using a dynamic whole blood coagulation analyses like thromboelastometry, however the temperature of the analyses is ambiguous. The aim was to examine whether thromboelastometry differed when analyzed at 33°C and 37°C in hypothermic and normothermic patients. Methods: We included 40 patients treated with hypothermia (33 1°C) after cardiac arrest. The first blood sample was obtained at hypothermia and the second at normothermia. Each blood sample was analyzed simultaneously at 33°C and 37°C by thromboelastometry (ROTEMâ) using standard assays (EXTEMâ, INTEMâ, FIBTEMâ,and HEPTEMâ). Data regarding antitrombotic drugs were collected using medical records. Results: Comparing the ROTEMâ analyses an increased clotting time, a lower maximum velocity, and an increased time to maximum velocity (all P-values < 0.008) was found at 33°C compared to 37°C independent of the patients being hypothermic (median 33.1°C, range 32.6–34.4°C) or normothermic (median 37.5°C, range 35.8–38.3°C). However, time to maximum velocity in EXTEMâ deviated showing no difference when analyzed at 33°C and 37°C in hypothermic patients (P = 0.63).


10

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O3-03 Outcomes and quality of life in lung transplant patients re-admitted to the Intensive Care Unit (ICU) Rajesh M Shetty1, Priya Nair2, Allan R Glanville2 1 Manipal Hospital, India, 2St Vincent’s Hospital, Australia Purpose: (1) To describe the clinical characteristics and outcomes of lung transplant patients re-admitted to the Intensive Care Unit (ICU) and (2) To assess the quality of life (QOL) of patients who survive their re-admission and compare this to lung transplant survivors who did not require ICU re-admission. Methods: Sixty-three patients re-admitted to ICU subsequent to their lung transplant and 66 randomly selected patients of 238 lung transplant patients over a seven year period in a single institution were studied retrospectively. Demographic, clinical and outcome data for each ICU re-admission were collected. Hospital survivors were requested to complete the SF-36v2 questionnaire to assess their quality of life. Results: Indications for ICU admissions varied and were most commonly (76%) related to infection, rejection or other graft related indications. The majority of patients (77.8%) had one ICU admission. The mean APACHE II score was 17.73 (SD 7.35), 24 patients (38%) required invasive mechanical ventilation and the mean ICU length of stay was 4.53 (SD 4.68 days). The overall ICU mortality was 3%. The return rate of the QOL questionnaire was 70%. The summary scores for the Physical and Mental Health components in the ICU survivors were 42.21 (SD 12.81) and 45.68 (SD 12.37) respectively, compared with 45.32 (SD 11.28) and 47.79 (SD 9.25) in the control group, which was not significantly different. Conclusions: Overall clinical and QOL outcomes of lung transplant patients requiring readmission to ICU were good and compared favourably with patients who did not require an ICU re-admission.

O3-04 Clearance of Nitrate and Nitrite - An observational study of continuous renal replacement therapy on intensive care patients Fredrik Eidhagen Karolinska Sjukhuset, Sweden Background: Nitric oxide (NO) has sparked a vast scientific interest in the past decades. It is involved in various vital processes such as upholding vascular homeostasis and regulating mitochondrial function. The supposedly stable end products of NO oxida-

tion, nitrate and nitrite, have been established to play a crucial part in the bioavailability of NO, since they can be recycled back to bioactive NO. This study aimed to examine if CRRT had a scavenging effect on arterial plasma nitrate and nitrite as well as determine the clearance and mass removal rate of these anions. Methods: In this observational study, 9 patients with acute renal failure treated with PrismaFlex CRRT system were included. To determine nitrate and nitrite levels samples from arterial blood were collected daily during and after CRRT. Samples were also collected from the CRRT system in order to determine clearance and mass removal.. Results: Arterial plasma nitrate decreased significantly during CRRT, 59% after 24 h, and increased towards baseline levels 24 h after termination. In contrast, nitrite levels were not significantly altered by CRRT. Clearance of nitrate ranged from 54.0 4.0 to 118.3 36 ml/min at effluent flow rates of 50–80 ml/min. Mass removal rate of nitrate declined initially and stabilized after 12 h and correlated to arterial nitrate levels. Conclusions: CRRT had a scavenging effect on nitrate. Nitrate passes freely across the CRRT filter, exhibiting a clearance superior to both creatinine and urea. Keywords: Nitric oxide, Nitrate and Nitrite, Continuous Renal Replacement Therapy, Clearance

O3-05 Left ventricle outflow tract area and derived cardiac output by two- and three-dimensional echocardiography compared with cardiac CT Angiography and thermodilution Karin Graeser1, Mikhail Zemtsovski1, Jesper Kjaergaard2, Klaus F. Kofoed2, Hasse Moller-Sørensen1, Jens Chr. Nilsson1 1 Department of Cardiothoracic Anesthesiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, 2Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital Background: Cardiac output (CO) can be estimated by echocardiographic assessment of left ventricular outflow tract (LVOT) cross sectional area (CSA) and LVOT flow, but accuracy and precision may be limited.1 The objectives of this study were to compare: (1) CSA of the LVOT measured by 2D and 3D echocardiography with CSA measured by cardiac CT angiography (CCTA); and (2) CO estimated by 2D and 3D echocardiography with CO measured by thermodilution. Method: Sixty-one patients scheduled for elective heart surgery were included, 19 of whom were examined by CCTA the day before surgery. All echocardiographic measurements were performed blinded from thermodilution and CCTA measurements and analysed post hoc. Mean differences (bias) and limits of agreement (LOA) were calculated according to the Bland and Altman method.2 Results: CSA by 2D and 3D echocardiography was 3.3 and 4.5 cm2 respectively, had a bias of 1.5 (LOA: 2.77 to 0.15) and 0.27 (LOA: 1.02 to 0.48) cm2, respectively, compared with CCTA. CO by 2D and 3D echocardiography was 3.0 and 4.0 l/min respectively, had a bias of 0.8 (LOA: 2.9 to 1.3) and 0.3 (LOA: 1.8 to 2.4) l/min, respectively, compared with thermodilution. Conclusion: 2D echocardiography consistently underestimates LVOT CSA. The bias increases with larger CSA. 3D echocardiography also underestimates LVOT CSA, but shows smaller bias and narrower LOA than 2D. CO derived from 2D echocardiography has a large bias and both 2D and 3D have wide LOA, which may limit the usefulness of the methods to perioperative measurement of CO.


11 References: 1. Bhavsar R, Juhl-Olsen P, Sloth E, Jakobsen CJ. Agreement between cardiac output by four dimensional echocardiography and thermodilution method is poor. Acta Anaesthesiol Scand 2012; 56: 730–7. 2. Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. The Lancet 1986; feb: 307–10. Picture 1: https://www.eventure-online.com/parthen-uploads/ 154/SSAI/img1_271385_nH24cDmT2z.jpg.

O3-06 Acute right ventricular afterload increase by hypoxic pulmonary hypertension – establishing a pig model for further studies Nils Kristian Skjærvold Trondheim University Hospital, Norway Background: Intact animal models are vital in order to improve our understanding of the pathophysiology of acute right ventricular failure. Previous models are hampered with their invasiveness; this is unfortunate as the pulmonary circulation is a low-pressure system that needs to be studied with intact pericardium in closed chest animals. The aim of this study was to examine the use of hypoxic pulmonary vasoconstriction as a means to increase the afterload of the right ventricle. Material and methods: Eight pigs were anesthetized and mechanically ventilated. Their central vasculature was cannulated and monitored with pressures and blood gases. The respirator was manipulated in order to yield sub-normal FiO2 values. After stable baseline measurements, the FiO2 was lowered to achieve a mean pulmonary pressure (mPAP) in the individual animal above 25 mmHg. Results: The mPAP of the animals were increased from 18.3 (4.2) to 28.4 (4.6) mmHg with a lowering of FiO2 from 0.30% to 0.15 (0.024)%. The animals’ individual baseline mPAP varied substantially; so did their response to hypoxia. The reduced FiO2 level yielded an overall lowering in oxygen offer, but the global oxygen consumption was unaltered. Conclusion: We showed in this study that the mPAP and the PVR could be raised by approximately 100% in the study animals by lowering the FiO2 from 0.30% to 0.15 (0.024)%. The response is individual, as well as the baseline mPAP. The method should in principle be reversible, although not studied in this work. We therefore present a novel method for reversible, minimal-invasive (closed chest, closed pericardium) method for right ventricular afterload manipulations intended for future studies on acute right ventricular failure.

O3-07 Hemodynamic consequences following surgical aortic valve replacement versus transcatheter aortic valve implantation – a randomized study Pia Katarina Ryhammer, Jakob Greisen, Carl-Johan Jakobsen Department of Anaesthesiology & Intensive Care, Aarhus University Hospita, Denmark Introduction: The trans-apical aortic valve replacement (a-TAVI) and the surgical aortic valve replacement (SAVR) are two different methods of treating severe aortic valve stenosis. The purpose of this study was to compare perioperative haemodynamics in

patients going through either procedure to evaluate the anaesthetic and surgical impact. Methods: The present study is a subset of a multicentre trial comparing the two methods in patients with valvular aortic stenosis (AS), who were eligible for either procedure, and thus were randomized to one of them. 58 patients from our institution were included and all available data on haemodynamics as well as arterial blood gases and s-creatinine were gathered and compared. All patients were monitored invasively during anaesthesia and recovery. Results: The SAVR group had lower cardiac index (CI) and stroke volume index (SVI) (P < 0.001). At the end of surgery the SAVR group had a higher pO2 (P < 0.0001), a higher s-lactate (P = 0.003) and a lower haematocrit (P = 0.045) than the TAVI. The SAVR group received more fluids (P < 0.0001) and a more pronounced increase in s-creatinine (P = 0.034) was seen in the TAVI group. No differences in the perioperative use of inotropes, vasoconstrictors or vasodilators Conclusions: The main finding in the present study was that the surgical and anaesthesiological management of a-TAVI resulted in a more stable haemodynamic situation both per- and postoperatively compared to SAVR patients. The haemodynamic changes during anaesthesia and SAVR operation may potentially lead to hypoperfusion of organs. The advantages may be even more pronounced now as TAVI today is a treatment that is well established.

O3-08 Hemofiltration in ex vivo lung perfusion – a study in experimentally-induced pulmonary edema Tobias Nilsson1,5, Christoffer Hansson2,4, Andreas Wallinder2,4, CarlJohan Malm2,4, Martin Silverborn2,4, Sven-Erik Ricksten1,5, G€oran Dellgren2,3 1 Department of Cardiothoracic Anesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden, 2Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden, 3Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden, 4Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden, 5Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden Objectives: Ex vivo lung perfusion (EVLP) could potentially reduce pulmonary edema. In a pig model with induced pulmonary edema, we evaluated the effect of hemofiltration (HF) during EVLP on lung function, perfusate oncotic pressure and lung weight. Methods: In anesthetized pigs (n = 14), pulmonary edema was induced by a balloon in the left atrium, combined with crystalloid infusion (20 ml/kg), for 2 h. The lungs were harvested, stored cold for 2 h and randomized to EVLP, with (HF group, n = 7) or without (noHF group, n = 7) a hemofilter. EVLP was performed with cellular perfusate at a hematocrit of 10–15%. Oncotic pressure, lung performance and weight were measured before and after 180 min of EVLP reconditioning HF. Results: After in vivo induction of edema, PaO2/FiO2 and compliance decreased by 63% and 16%, respectively. PaO2/FiO2 was considerably improved at first evaluation ex vivo in both groups. HF increased oncotic pressure by 43% and decreased lung weight by 15%. The effects were negligible in the noHF group. Compliance decreased in both groups during reconditioning, although less so in the HF group (P < 0.05). PaO2/FiO2, shunt fraction and oxygen saturation remained unchanged in both groups. Pulmonary flow


49 1. Bergman S. Perioperative management of the diabetic patient. OralSurgOralMedOralPatholOralRadiolEndod.2007;103:731

O18-02 Postanaesthesia care unit as a temporary admission location Leila Niemi-Murola, Anna-Maria Troberg, Tomi Niemi, Irma Jousela University of Helsinki, Helsinki University Hospital, Finland Introduction: Some postoperative patients stay in the postanaesthesia care unit (PACU) for extended observation. The purpose of this retrospective study was to profile these patients causing a considerable work load in the PACU. Methods: In Helsinki University Hospital, Meilahti the duration of extended observation is defined as 8 h. Two busiest months in the PACU (July = 45 and November = 42 patients needing extended observation) and two calmest months (April = 33 and December 35 patients) were included in the study. The data was extracted from the electronic patient files (PICIS, Miranda). Results: Mean duration of the prolonged observation was 17.6 h (SD 13.0). Third of the patients were classified as ASA III and 45% were ASA IV and 98% had undergone emergency surgery. One third had undergone vascular surgery and 37% had had gastrointestinal operation. The reasons for prolonged observation were oliguria, unstable hemodynamics and respiratory insufficiency, 40% of patients has all these symptoms. From the PACU, 65% of the patients were transferred to a ward and 37% were eventually discharged at home. Only 6% were explicitly classified as non-eligible to intensive care unit. In 52% of the cases, there were no text in the patient records. Conclusions: Patients needing prolonged observation in the PACU are often demanding because of their unstable condition. Despite their poor preoperative health status, the prognosis is good. Prior to the emergency operation, their postoperative care unit should be more explicitly determined in order to avoid unplanned workload to PACU.

O18-03 Computerized screening for peri-operative risk factors in the Preoperative Assessment Clinic of a tertiary university hospital: First results after implementation into clinical routine Bruno Neuner1, Finn Radtke1, Christoph Rosenthal2, Henning Krampe2, Claudia Spies2 1 Charite – Universit€atsmedizin Berlin, Germany, 2Charite – Universit€atsmedizin Berlin, Germany Introduction: To analyze in a preoperative assessment clinic feasibility and primary results of a computerized assessment of behavioral and psychological risk factors in adult elective surgery patients. Methods: Between January and June 2014 and after approval of the local data protection officer screening questions deriving from the Post-operative Quality of Recovery Scale, PQRS, regarding pain, nausea, well-being, anxiety, and questions on substance use were administered. In case of a positive screen further standardized questionnaires were added. Results: From January till June 2014, one study nurse could cover 74 / 95 working days (77.9%). Overall 1271 / 2799 (45.4%) patients were screened with 1235 (98.8%) complete screenings. Overall 517 (41.9%) screened positive regarding pain, of these 75 (6.1%) with

VAS-scores ≥ 75 points, indicating severe pain; 60 (4.9%) positive regarding nausea (of these 6 [0.5%] with an ‘orange score’ and 5 [0.4%] with a ‘red score’ in the Short Nutritional Assessment Questionnaire, SNAQ); 322 (26.1%) positive regarding impaired wellbeing (of these 41 [3.3%] with < 7 points in the WHO-5 well-being index, indicating depressive disorder); and 424 (34.3%) positive regarding anxiety (of these 29 [2.3%] ≥ 6 points in the Patient Health Questionnaire-4, PHQ-4, indicating anxiety or depressive disorder). Binge drinking and illicit drug use was reported by ~5% of patients. Conclusion: A routine computerized 2-stage-screening in a preoperative assessment clinic is feasible. Around 6% of patients report severe pain, 1% present symptoms related to malnutrition, 3% report symptoms indicative for depressive disorders and 2% symptoms indicative for anxiety disorders.

O18-04 Major complications and mortality at 90 days following minimally invasive esophagectomy (MIE) for esophageal adenocarcinoma

Kaisa Anitta Nelskyla€1, Emmi Ylikoski2, Jari R€as€anen2, Juha T. Kauppi2, Jarmo Salo2 1 Helsinki University Hospital, Finland, 2Helsinki University and Helsinki University Hospital, Finland Introduction: Adenocarcinoma is the most common type of esophageal cancer in the Western countries. The survival has increased in operable mucosal and locally advanced tumors, especially with preceding neoadjuvant chemotherapy. The aim of this study was to analyze the factors behind 90 days mortality. Methods: We analyzed retrospectively data of patients undergoing MIE due to esophageal adenocarcinoma between VIII/2009 and XI/2014 in Helsinki University Hospital. The recovery and hospital dispatch we carefully followed, as well as morbidity up to 30 days and mortality up to 90 days. Results: Data from 75 patients was collected.At30 days mortality was 1% (one patient) and at 90 days 4% (3 patients). Patient characteristics are presented in Table 1. The cardiovascular performance was well preoperatively evaluated for patient No 1 and no alarming signs were marked. The cause of death was intraoperative pulmonary embolism. Patient No 2 was acidotic preoperatively (pH 7,2/BE-18) and kidney failure requiring RRT developed. The recovery was further compromised by leakage, pneumonia, minor pulmonary embolism and sick sinus syndrome. Patient No 3 recovered well and was discharged within 13 days. The patient died of bilateral neutropenic pneumonia due to postoperative cytostatic medication. Patient No 4 suffered from serious ventilation and oxygenation problems throughout perioperative period. The patient died of ARDS and consecutive fibrosis of the lungs. Discussion: Despite MIE technique is still connected major complications and mortality up to 3 months postop which can be difficult to predict based on preoperative parameters. Mortality is mainly connected to pulmonary complications.

Source: https://www.eventure-online.com/parthen-uploads/154/S SAI/img1_263635_ffb3fhpcV2.jpg


13 Conclusions: For stable PICU patients a restrictive RBC transfusion trigger is used in the Nordic countries, whereas a more liberal trigger is used in neonates with respiratory failure. In other subgroups practices vary widely. This study confirms the controversies concerning RBC transfusions in critically ill children and neonates and the need for randomised clinical trials. Table Transfusion triggers used in Nordic PICUs and NICUs. Source: https:// www.eventure-online.com/parthen-uploads/154/SSAI/img1_265034_MnYPbTgy54.png

Twenty-one (70.0%) of the departments were not able to report the number of paediatric anaesthesia-related adverse events. Laryngospasm, hypoxia, and intubation difficulties were the most frequently reported adverse events in children. Minor injuries and near misses were considered underreported. Conclusions: A large number of systems for reporting adverse events is used in the Nordic university hospitals. Most of the heads of the anaesthesia departments were not aware of the type and frequency of adverse events, but consider them to be underreported. A uniform validated anaesthesia-specific reporting system should be implemented in all Nordic countries in order to improve future quality of reporting adverse events.

O4-04 Practical tooltips for peripheral nerve blocks placement in paediatric patients Iva Vassileva Vesselinova1, Rajiv Gambhir2, Marianne Berg3, Johan Torngren4 1 Odense University Hospital, Denmark, 2Aarhus University Hospital, Denmark, 3Karolinska University Hospital, Sweden, 4Sahlgrenska University Hospital, Sweden

O4-03 How are paediatric anaesthesia-related adverse events reported at university hospitals in the Nordic countries? Per Mattsson1, Gabriele Hanke2, Jenni Vieri3, Atle Ulvik4 1 Karolinska University Hospital, Sweden, 2AKK, Children’s Hospital Altona, Germany, 3Tampere University Hospital, Finland, 4Haukeland University Hospital, Norway Introduction: Reporting of adverse events in healthcare may play a key role in learning from mistakes and thus improve patient safety. The aim of the present study was to investigate how adverse events in paediatric anaesthesia are reported at university hospitals in the Nordic countries. Methods: The heads of anaesthesia departments at all Nordic university hospitals were asked to answer a questionnaire concerning reporting of adverse events in 2013. The data was collected by email and telephone. Results: Of 32 eligible hospitals 30 (93.8%) answered the questionnaire. All the hospitals had at least one written system for reporting of adverse events. Twenty different systems were used. Seven systems were anaesthesia-specific. None of the systems was specifically designed for reporting of adverse events in paediatric anaesthesia. Reported adverse events ranged from 4 to 147 (median 35). Physicians, nurses, other staff and relatives were able to report.

Introduction: Peripheral nerve blocks (PNB) are gradually gaining in popularity due to the wide spread of ultrasound. Furthermore, emerging data show advantages in terms of safety, high quality analgesia, beneficial effects on the surgical stress response and improved outcomes. Although PNB are described in the literature, their implementation in the daily practice is still limited. The main reasons for this are problems with selection of appropriate block, choice of equipment, (sono)anatomy landmarks and blockade technique. We were assigned the task to addresse these issues and develop practical tooltips for PBN placement in children as part of our SSAI training in paediatric anaesthesia and intensive care. Methods: We conducted survey of the current literature to substantiate indications, contraindications, common approaches, techniques, equipment and local anaesthetics applied with the available evidence for the most commonly used PNB: interscalene, supraclavicular, infraclavicular, axillary, fascia iliaca, femoral and popliteal. In addition, we took bedside pictures of the sonoanatomy landmarks for illustration. Results: Based on data from the survey, we developed concise tooltips to facilitate the performance of PNB in children. Conclusions: The practical tooltips summarise the current evidence for practice of PNB in children. They are primarily aimed as guiding tool for anaesthesiology trainees or infrequent practitioners of these blocks, rather than as a comprehensive training material. We expect the tooltips to be helpful in the daily practice and to serve as inspiration for further exploring this field to the benefit of the paediatric patients.

O4-05 Tool-tip guide for truncal blocks in paediatric anaesthesia Marcus Nemeth1, Asta Aliuskeviciene2, Annika Liersch Nordqvist3, 4 € Alexander Onneby 1 Auf Der Bult Childrens Hospital, Germany, 2Aalborg University ane University Hospital, Sweden, 4Astrid Hospital, Denmark, 3Sk 0 Lindgren Children s Hospital, Sweden Introduction: The increased use of ultrasound provides an opening in the practice of regional anaesthesia in children. Some peripheral


14 nerve blocks would be difficult to apply in children only based on landmarks. We believe that the use of paediatric regional blocks varies a lot between different anaesthetic departments. Our aim was to develop structured practical instructions to increase the use of truncal regional anaesthetic blocks in children. Methods: A MEDLINE electronic search was performed using the terms ‘children’, ‘paediatric’, ‘regional anaesthesia’ and one of the following predefined truncal regional anaesthetic blocks: ‘ilioinguinal/iliohypogastric nerve block’, ‘penile block’, ‘paravertebral block’, ‘intercostal block’, ‘rectus sheath block’, and the ‘transversus abdominis plane block’. We included clinical studies and review articles. We limited our search to the last 10 years. Results: We identified relevant literature references and developed a practical tool-tip guide for truncal regional anaesthetic blocks in children using a uniform three step approach. Step ‘1’ includes indications, preparations, local anaesthetics and additives. Step ‘2’ describes the anatomical landmarks and sono-anatomy. Step ‘3’ comprises block performance and specific characteristics. Conclusions: We summarized six truncal regional anaesthetic blocks by using a uniform three step practical approach in children. We hope that this tool-tip will stimulate further use of regional anaesthesia in children.

O4-06 Survey of paediatric regional anaesthesia in the Nordic Countries Adamvon Cappeln1, Kosti Koivisto-Kokko2, Mattias Larsson3, Kristoffer Stensrud4 1 Odense University Hospital, Denmark, 2Turku University Hospital, Finland, 3Queen Silvia children0 s Hospital, Sweden, 4Rikshospitalet, Norway Introduction: Regional anaesthesia is widely used in paediatric anaesthesia in the Nordic countries. Randomised controlled trials comparing different regimes of regional anaesthesia in the paediatric population are sparse. Details on the usage in the Nordic countries are unknown. Using a Web-survey we set out to characterise the current use of regional anaesthesia in the Nordic Countries. Methods: Heads of paediatric anaesthesia departments in University-hospitals in the nordic countries were invited to participate in a web-survey regarding their use of epidurals, caudals, spinals and nerve-blocks in neonates, infants and children. 19/22(86%) responded. For epidurals some respondents co-reported their use of caudal blocks so we have chosen not to report the data on epidurals. Results: 16/19 (14/19 in neonates) use caudal blocks. Bupivacaine is used in 9/16 (10/14), Ropivacaine 8/16 (5/14), Levobupivacaine 5/16 (4/14), No one uses lidocaine. Norway and Denmark mostly use Bupivacaine where Sweden and Finland mostly use Levobupivacaine or ropivacaine. Caudals are placed using landmark-technique in all, but one department using ultrasound. 11/16 (7/14) add clonidine, epinephrine is added by 3/16 (2/14). 6/19 (4/19) use spinals. Only one department use spinals in unsedated neonates despite the apparent reduction of postoperative apnea. 18/19 (6/19) use nerve-blocks. Nerve-blocks are only placed in neonates in Denmark and Finland. Ultrasound is used by 18/19 departments thereby replacing nerve-stimulator and landmark technique. 7/19 still use bupivacaine for nerve-blocks. Conclusions: Caudals are widely used. spinals are uncommon. Nerve-blocks are common and placed under ultrasound guidance.

O4-07 Scandinavian practice guidelines on neuraxial blocks in pediatric anesthesia: a project for SSAI’s 9th Scandinavian Training Program in Pediatric Anesthesia and Intensive Care 2013– 2015 Felix Liebau1, Jesper Hedegaard2, Mads Astvad3 1 Karolinska University Hospital Huddinge, Sweden, 2Aarhus University Hospital, Denmark, 3Odense University Hsopital, Denmark Introduction: As part of a project for SSAI’s 9th Scandinavian Training Program in Pediatric Anesthesia and Intensive Care, we collected and resumed available information on practice guidelines for pediatric neuraxial blocks in the Scandinavian countries. Methods: The scientific literature was researched using PubMed and Web of Science searches, and personal inquiries were made to the specialized departments of pediatric anesthesia in Denmark, Finland, Norway and Sweden. Results: National guidelines of the specific scope described were not found. Local guidelines from Lund and Stockholm university hospitals were retrieved. Other state of the art documentation was found in a national guideline from the German Society of Anesthesiology and Intensive Care, and in several review articles in the scientific literature. Various techniques of neuraxial anesthesia are generally accepted as a safe mode of perioperative analgesia in all age groups. The reported frequency of long-term complications is very low. Placing a block in an anesthetized patient is accepted practice. Of the individual techniques, spinal anesthesia is rarely recommended for routine use. Lumbal and thoracal epidural anesthesia are well-documented but apparently used with restraint. Caudal anesthesia is well researched,comprehensively described and widely recommended for a variety of indications, usually in the form of single-shot or repeated injection, while catheter techniques are infrequently recommended for routine use. Conclusions: While techniques of neuraxial anesthesia are wellresearched and apparently routinely used in pediatric anesthesia in the Scandinavian countries, national guidelines remain to be developed.

Free Paper Session 5 – Paediatric Anaesthesia O5-01 Peri-operative complications of cochlear implant surgery in children; A retrospective analysis Ravinder Kumar Pandey, Vanlal Darlong, Professor Chandralekha, Dalim Kumar Baidya, Puneet Khanna, Jyotsna Punj, Rakesh Kumar All India Institute of Medical Sciences, India Introduction: Cochlear implant (CI) is a commonly performed surgery for hearing loss in pre-school and school children. Recently, CI surgeries are being performed in infants & below 2 years of age have improved speech outcome, intelligence and better quality of life. CI surgeries at early childhood are not associated with increased surgical risk and complications. However, data on anesthesia management and complications are sparse. We retrospectively reviewed the data of our institute from January 2007 to December 2012. Methods: Medical records and anesthesia charts of all patients, who had CI under GA during this period, were reviewed. Idiopathic cause was the most common etiology found. Other common causes were birth asphyxia, prematurity, meningitis, ototoxicity, TORCH etc. Information related to the demographic profile, PAC, anesthetic techniques and perioperative complications were collected and


15 analyzed. All the patients received standard premedication and GA technique with ETI. Combination of fentanyl and morphine along with iv paracetamol was most commonly used analgesia. Results: 193 patients had undergone CI surgery for pre lingual (175) and post lingual (15) deafness. Mean age and weight at implantation was 3.44 years and 16.3 kg. Difficult intubation was encountered in 3 patients. Complications like laryngospasm at extubation (4.73%), emergence agitation (2.63%) and PONV (1.05%). Major surgical complications were CSF leak without meningitis (3.15%), device migration/failure (1.05%) and flap infection (1.57%). Conclusion: CI under GA in small children is safe and complications are similar to general pediatric population. Surgical complications although more frequent were predominantly minor and selflimiting.

O5-02 Case presentation: two infants presenting for elective ventriculoperitoneal shunt were found to have life threatening electrolyte imbalance Margaret Ekstein, Shirley Friedman, Idit Matot Tel Aviv Medical Center, Israel Introduction: Neonatal hydrocephalous may be a complication of prematurity, infection or developmental anomaly. Two infants, after CSF diversion procedures and serial CSF aspirations, presented for elective VP shunt (Table 1). Case 1: A 29-week infant, 1.270 kg, with IVH and necrotizing entero-colitis had hydrocephalous with poor peritoneal absorption; a ventriculo-subgaleal shunt(VSG) was placed for serial CSF aspirations:170–200 ml/2 days. On admission for elective VP shunt (age 11 months), he was irritable with sunset eyes, tense subgaleal CSF pocket and fontanelles. Case 2: A 41-week infant, 4.2 kg, with hydrocephalous and meningomyelocele(MMC) underwent MMC closure on day2 and omaya reservoir placement for serial CSF aspirations (70–80 ml/23 days). She presented for elective VP shunt(age 2 months), paraplegic, lethargic with bulging fontanelles, sunset eyes, capillary refill time > 5 s. Discussion: Perinatal hydrocephalous (0.48–0.81/1000 live-births) occurs most commonly with IVH or MMC. Serial CSF aspirations temporarily manages hydrocephalous. Severe hyonatremia:[Na+] < 120 mEq/l causes: nausea, headaches, progressing to lethargy, seizures, coma, respiratory arrest: resembling high ICP. Both infants had hypo-osmolar - hyponatremia, hyperkalemia, acidosis and increased ICP. Hypovolemia with renal failure perpetuates hyponatremia, hyperkalemia and acidosis; endocrinopathy could too. Definitive diagnosis required the establishment of whether their depletional hyponatremia was due to renal vs. extra-renal losses.

Thyroid, cortisol, aldosterone and renin activity were appropriate, urine FeNa+ and [Na+]: [K+] ratio were low. Thus, infants had severe dehydration and received: 3%saline, 0.9%saline and VP shunting. Life threatening fluid/electrolyte imbalance has been described in children with choroid-plexus tumors and copious CSF drainage and in PICU patients with externalized ventricular drains; greater sodium fluctuations is associated with increased mortality.

O5-03 Early postoperative acute kidney injury in children undergoing scoliosis surgery and hyperchloremia at the end of surgery Shirley Friedman1, Lilach Zac2, Anat Cattan2, Dror Ovadia2, David Eduard Lebel2, Idit Matot2 1 “Dana-Dwek” children’s hospital, Tel-Aviv medical center, Israel, 2Tel Aviv Medical Center, Israel Introduction: Studies in healthy volunteers suggest that hyperchloremia may be associated with impaired renal cortical perfusion. In critically ill patients, the administration of chloride restrictive fluids was associated with a decrease in the incidence of acute kidney injury (AKI) as well as with a reduced risk of in-hospital mortality from sepsis. Studies in surgical children are missing. The aims of the present study were to evaluate the incidence of early postoperative AKI in children undergoing scoliosis surgery and the association between postoperative AKI and serum chloride (SCl), serum base excess (SBE) and pH. Methods: Retrospective cohort study of children undergoing scoliosis surgery in a tertiary medical center. AKI was defined according to the KDIGO criteria. The primary outcome was 12 h postoperative AKI. Secondary outcomes were levels of SCl, pH and SBE perioperatively. The study was approved by the local ethics committee. Results: AKI was diagnosed in 7(9%) patients 12 h postoperatively and was associated with a higher SCl level at the end of surgery. In comparison to patients without AKI, SBE was significantly lower at 6 h and 12 h postoperatively in those who developed AKI (Table 1). No differences were documented in pH and in the volume and type of crystalloids administered during surgery and in the first 12 h postoperatively between patients with and without AKI. Conclusion: AKI occurs in pediatric patients undergoing scoliosis surgery. Early postoperative AKI was significantly associated with hyperchloremia at the end of surgery. We suggest close perioperative monitoring of chloride level with restrictive usage of chloride solutions. Table 1 Demographics, SCl and SBE in patients with and without AKI. Source: https://www.eventure-online.com/parthen-uploads/154/SSAI/img1_265013_Mp GwfLSq2M.png

Table 1 Source: https://www.eventure-online.com/parthen-uploads/154/SSAI/ img1_265006_oGuy86WHJE.jpg


16 O5-04 Comparison of the success of two techniques for the endotracheal intubation with C-Mac videolaryngoscope straight blade in paediatric patients: a randomized study Renu Sinha, Ankur Sharma, Bikash Ranjan Ray, Ravinder Kumar Pandey, Vanlal Darlong, C. Chandralekha All India Institute of Medical Sciences, India Introduction: C-Mac video laryngoscope (Karl Storz endoscopy, Tuttlingen, Germany) with standard pediatric sized blades is a newly available technology with limited case reports experience. Ease of endotracheal intubation for C-Mac staright blade has not been evaluated. Method: Sixty children of either sex weighing 3–15 kg with normal airway for surgery under general anesthesia requiring endotracheal intubation were included. C-MAC straight blade was inserted thorough midline and epiglottis was lifted to visualize the glottis. Endotracheal intubation was attempted with or without styleted ETT according to the randomized group (group S or group WS). Time to intubation and total time for the procedure was recorded. Number of attempts, any reposition of blade and any maneuvers to ease intubation was also noted. Any desaturation, bradycardia and other complications were recorded. Results: Age varied from 3 months to 6 years. Weight of the children ranges from 2.1–15 kg, time to intubation in group S varied from 8 to 55 s and in group WS from 9-60 seconds. In group S no second attempt was required for intubation in comparison to group WS where second attempt was needed in two children. Conclusions: There is o statistical difference in time to intubate with styleted and without styleted ETT with C-Mac straight blade size 0 and 1 in children weighing upto 15 kg. Delay in intubation is more due to small epiglottis and due to slippage of tongue on the right side of the blade thus obstruction the view and decreasing the space.to negotiate the ETT.

O5-05 AirQ intubating laryngeal mask airway as a conduit for blind orotracheal intubation in children: ‘an interventional clinical trial’ Ravinder Kumar Pandey, Rajkumar S, Jyotsna Punj, Vanlal Darlong, Chandralekha, Minu Bajpai, Vimi Rewari All India Institute of Medical Sciences, India Introduction: In low resource settings, management of difficult pediatric airway is really challenging due to limited options, especially unavailability of FOB. Therefore in such remote places blind endotracheal intubation (ETI) using intubating LMA as a conduit is a good option. Methods: After IEC approval 60 ASA grade I & II children were enrolled. In all children, after standard premedication and anaesthesia technique, an appropriate sized AirQILA was placed. Patient’s glottis view was assessed by FOB (through AirQILA) in both positions. However, the trachea was intubated blindly in supine position by passing appropriate sized endotracheal tube (ET) through AirQ ILA. Parameters assessed were number of attempts of AirQILA and ET placement, glottis view, perioperative airway complications, and time for AirQILA and ET placement. Results: Most of our study population was male, weight < 15 kg. Grade I glottic view was the commonest. Success rate of blind ETI was 83.37% in two attempts. However in 16.67% patients, blind ETI was failed. The mean time for successful AirQILA and ET placement were 16.64 s and 20.57 s. respectively. Success rate for

blind ETI was higher in children < 15 kg (P = 0.021). Overall, desaturation, trauma and ET displacement during removal of Air QILA occurred in1.7%, 1.6% and 3.3% respectively. Conclusion: AirQ ILA is a user friendly, safe, easy to place SGD with an excellent airway seal and low airway morbidity in pediatric population. It is particularly useful as a conduit for blind ETI in supine position, and may be an effective alternative to FOB in low resource settings.

O5-06 Thromboelastometry detects impaired platelet aggregation during but not after paediatric cardiac surgery

Birgitta, Sofia Romlin1, Fredrik So€derlund1, Anders Jeppsson2 1 Queen Silvia Childrens Hospital, Sahlgrenska University Hospital, Sweden, 2Department of Molecular and Clinical Medicin, Sahlgrenska Academy, University of, Sweden Background & Aim: Low platelet count and/or impaired platelet function increases the risk of bleeding complications in cardiac surgery. Reliable detection of impaired platelet function may improve treatment. We investigated whether thromboelastometry detects clinically significant perioperative ADP-dependent platelet dysfunction. Methods: Fifty-seven paediatric cardiac surgery patients were included in a prospective observational study. Modified rotational thromboelastometry (with heparinase) and multiple electrode platelet aggregometry were analyzed at five time points before, during, and after surgery.The accuracy of thromboelastometric indices of platelet function (maximum clot firmness (MCF) and clot formation time (CFT), to detect ADP-dependent platelet dysfunction (defined as ADP-induced aggregation of £30 units) was calculated with receiver operating characteristics (ROC) analysis, which also was used to identify optimal cut-off levels. Positive and negative predictive values for the identified cut-off levels to detect platelet dysfunction were determined. Results: MCF and CFT had a high accuracy to predict platelet dysfunction during cardiopulmonary bypass (area under the ROC curve 0.89 and 0.83 respectively, both P < 0.001) but not immediately after CPB (0.64 and 0.67, or at arrival to ICU (0.53 and 0.60). Optimal cut-off levels were MCF < 43 mm and CFT > 166 s. The positive and negative predictive value were high during cardiopulmonary bypass (87% and 67% respectively for MCF > 43 mm; 80% and 100% for CFT > 166 s) but markedly lower after surgery. Conclusion: In paediatric cardiac surgery, thromboelastometry has acceptable ability to detect ADP-dependent platelet dysfunction during but not after cardiopulmonary bypass.

Free Paper Session 6 - Pain Medicine/Orthopedic Anaesthesia O6-01 Treatment and outcome of patients with hip fracture Kristofer Arnar Magnusson1, Gisli Heimir Sigurdsson1,2, Yngvi Olafsson3, Brynjolfur Mogensen1,4, Sigurbergur Karason1,2 1 University of Iceland, Iceland, 2University of Anesthesia and Intensive Care, 3Department of Orthopedics, 4department of Emergency Medicine, Landspitali National University Hospital, Iceland Introduction: Hip fractures are common amongst the elderly and are associated with increased mortality. The aim of this study was to describe treatment and outcome in patients suffering a hip fracture.


17 Methods: A retrospective study on all hip fracture patients ≥ 60 years of age undergoing surgery at Landspitali University Hospital in the year 2011 with 18 months follow up. Results are shown as mean (SD; range) Results: The study group was made of 255 patients, 166 (65%) women (mean age 82.9 years; 8.1; 60–107) and 89 (35%) men (mean age 81.6 years; 7.7; 61–101). Mean delay from admission to surgery was 22 h (14; 3–77). Regional anaesthesia was given to 215 (85%) but general anaesthesia to 39 (15%). Mean length of stay in the orthopedic ward was 11 days (10; 1–51). Before the hip fracture 68% of the patients lived in their own home but 54% at the end of follow up (P < 0.001). Mortality at 30 days was 9%, after 6 months 20% and one year 27%. Mortality in hip fracture patients was eightfold higher when compared to the general population ≥ 60 years of age in age intervals of 10 years. Conclusion: Age, length of hospital stay and mortality was similar as in other studies but the proportion of men higher. Time from admission to surgery was within limits of international guidelines. Significantly fewer patients could live in their own home after the hip fracture and mortality was substantially increased compared with the general population of comparable age.

O6-02 A randomized comparison of continuous interscalene and supraclavicular brachial plexus blocks for postoperative analgesia for open rotator cuff repair Won Uk Koh, Ha Jeong Kim, Hyoek Seong Park, Woo Jong Choi, Hong Seuk Yang, Young Jin Ro Asan Medical Center, College of Medicine, University of Ulsan, South-Korea Introduction: Continuous interscalene brachial plexus block (ISB) is an approved modality for postoperative pain control after shoulder surgery. But ISB is associated with high incidence of hemidiaphragmatic paralysis. In this randomized double-blinded study, we examined the efficacy and incidence of hemidiaphragmatic paralysis of continuous supraclavicular block (SCB) compared with CSIB. Methods: Seventy five patients scheduled for elective open rotator cuff repair were randomly allocated to receive either ISB (n = 38) or SCB (n = 37). An initial bolus of 20 ml 0.375% ropivacaine was injected and continuous interscalene or supraclavicular catheter was inserted. After block, general anaesthesia was standardized. Hemidiaphragmatic excursion was tested before block, 30 min after block, 1 h after admission to postanaesthesia care unit (PACU) and 24 h after block. Postoperative pain scores were checked at PACU, 8 h, 24 h and 48 h after block and postoperative analgesic consumption was quantified to evaluate the efficacy of each block. Results: The incidence of hemidiaphragmatic paralysis was significantly lower in the SCB group compared with the ISB group (P < 0.001 at 30 min post-block and at PACU, P < 0.01 at 24 h). Postoperative pain scores were higher in the SCB group compared with the ISB group at the PACU (P < 0.001) but were comparable afterwards. No differences were observed in postoperative analgesic consumptions between the groups. Conclusions: Continuous SCB reduced the incidence of hemidiaphragmatic paralysis and shown to be an effective method for postoperative analgesia after open rotator cuff repair. The superiority of continuous ISB in postoperative analgesia was limited to immediate postoperative hours.

Fig. 1. Mean pain scores of each group after surgery. *P < 0.001. Source: https://www.eventure-online.com/parthen-uploads/154/ SSAI/img1_262417_dvCV1DF0AD.jpg.

O6-03 Improvement of postoperative analgesia by transversus abdominis plane block in patients with living donor hepatectomy Kentaro Tokuda, Hiroaki Shiokawa, Masako Murakami, Naoyuki Fujimura, Sumio Hoka Kyushu University Hospital, Japan Introduction: An ultrasound-guided transversus abdominis plane (TAP) block has been applied to postoperative analgesia for abdominal surgery. The aim of this retrospective study was to examine the effect of TAP block on opioid requirement in patients who underwent living donor hepatectomy. Methods: A total of 31 patients who underwent living donor hepatectomy were involved in this study. First consecutive 15 patients were treated with intravenous patient-controlled analgesia (IV-PCA) without TAP block (TAP (-) group), and the following 16 patients received IV-PCA with TAP block (TAP (+) group). Anesthesia was maintained with isoflurane, remifentanil and supplemental fentanyl during the surgery. IV-PCA with fentanyl was started before abdominal closure. Patients in the TAP (+) group received bilateral ultrasound-guided TAP blocks before

Source: https://www.eventure-online.com/parthen-uploads/154/SSAI/img1_ 264717_qEQoLg8oXN.jpg.


18 extubation. The TAP blocks were performed with 37–60 ml of 0.2–0.75% ropivacaine. Cumulative doses of fentanyl at 3, 6, 12, and 24 h after the surgery were analyzed. Visual analogue scale (VAS) at rest was measured on the 1 postoperative day (POD). Results: Cumulative doses of fentanyl via IV-PCA in the TAP (+) group (median 146, IQR 133, 191 (lg)) during first 3 h after the surgery were significantly lower than those in the TAP (-) group (median 210, IQR 163, 240 (lg), P < 0.05). However, there were no significant differences between the two groups in those at 6, 12, and 24 h after the surgery or in VAS on 1POD. Conclusion: This result suggests that TAP block reduces early phase postoperative opioid requirement after living donor hepatectomy.

O6-04 Multimodal analgesia: improvement perspectives Iveta Golubovska1, Aleksejs Miscuks2, Eriks Rudzitis1 1 Hospital of Traumatology and Orthopaedics, Latvia, 2University of Latvia, Latvia Introduction: The aim of this study was to evaluate the intensity of pain in orthopaedic hospital patients and to determine unsatisfactory pain management, identifying the possibilities for improvements in the future. Methods: Data collection included the Numeric Rating Scale (NRS) scores characterizing the intensity of pain. The maximum pain on the day of surgery, the mean pain on the day of surgery (D0), and the mean pain on first (D1) and second (D2) postoperative days were documented. The pain of an intensity from 0 to 3 was defined as mild pain, 4 to 6 – as moderate pain, 6 to 10 – as severe pain. Results: The maximum severe pain intensity on the day of surgery was experienced by 20.5% of patients; moderate – by 45.8%; mild – by 33.6%. The reported mean pain intensities according to the type of surgery were as follows: hip replacement – 2.79 1.6 (D0), 2.09 1.4 (D1), 1.35 1.2 (D2); knee replacement – 3.39 1.7 (D0), 2.98 (D1), 1.82 1.36 (D2); upper extremity surgery - 3.59 1.9 (D0), 3.4 1.7 (D1), 2.1 1.5 (D2); lower extremity surgery - 4.1 2.1 (D0), 3.49 1,42 (D1), 2.58 1.4 (D2); spine surgery- 3.31 1.58 (D0), 2.88 1.96 (D1), 1.83 1.74 (D2). Patients in the lower extremity group experienced unacceptable mean pain. The maximum pain intensities on the day of surgery was experienced by patients after a single-shot plexus brachialis block anaesthesia (5.24 2.4). Conclusions: Well-designed multimodal analgesia with special attention to single shot techniques may improve the pain management and functional outcomes after orthopaedic surgery.

perineural injection of local anaesthetics (LA).Our previous researches show possibility to detect the minimal fluctuations of the reflected light, which are caused by the inconsistent flow of pulsating blood after regional analgesia (RA) – photoplethysmographic imaging (PPGi) technique. In continuation of research supported by ERDF grant we returned to the light source where the peak wavelength changed to 760 nm. Methods: ASA I-III patients aged 18–90 years undergoing surgery of hand received US guided axillary brachial plexus blocks. Median, ulnar, radial and musculocutaneous nerves were blocked with LA. Palm surface video was recorded for 10 min after the block. Obtained data from 20 zones of the palm was analysed by photoplethysmogram imaging (PPGi) technology; the zones of successful and unsuccessful blockade were identified. Results: Two unsuccessful median nerve blocks from 20 measurements were determined using PPGi method. Verification of changes of the PPG signal amplitude after LA input on 20 measurements were averaged (R = 0.96, P < 0.001); on each measurement (R = 0.8 0.14, P < 0.001). Successful anaesthesia cases shoved PPG amplitude 1.46 0.25 before injection of LA and 3.76 0.44 after (R = 0.95, P < 0.005). In ineffective anaesthesia PPG amplitude was 1.00 0.19 and 1.69 0.83after the block. (R = 0.66, P < 0.005). Conclusions: A new approach of using PPGi provides the possibility to detect the zones with “unsuccessful” regional anaesthesia. The PPGi no-contact visualisation and mapping of RA is a quantitative optical method for the effective assessment of peripheral regional anaesthesia.

O6-05 Changes in amplitude of photoplethysmogram actualize ‘mapping’ to control the distribution of peripheral anesthesia prior hand surgery Aleksejs Miscuks1, Uldis Rubins2, Iveta Golubovska3 1 University of Latvia, Hospital of Traumathology and orthopaedics, Latvia, 2 University of Latvia, Institute of Atomic physics and spectroscopy, Latvia, 3Hospital of Traumatology and Orthopaedics, Latvia Introduction: The aim of prospective research was to develop a method for mapping the distribution of surgical anaesthesia after

Fig. 1. The map of PPG amplitude changes. Source: https:// www.eventure-online.com/parthen-uploads/154/SSAI/img1_2650 61_mmBeslaLny.jpg


ACTA PRIZE ORAL PRESENTATIONS

Best Free Papers AP-01 Prevalence and outcome of gastrointestinal bleeding and use of acid suppressants in acutely ill adult intensive care patients Mette Krag1, Anders Perner1, Jørn Wetterslev2, Matt Wise3, Mark Borthwick4, Stepani Bendel5, Colin Mcarthur6, Deborah Cook7, Niklas Nielsen8, Paolo Pelosi9, Frederik Keus10, Anne Berit Guttormsen11, Alma D Moller12, Morten Hylander Møller1 1 Copenhagen University Hospital, Rigshospitalet, Denmark, 2 Copenhagen Trial Unit, Centre for Clinical Intervention Research, Denmark, 3Department of Adult Critical Care, University Hospital of Wales, United Kingdom, 4Pharmacy Department, Oxford University Hospitals NHS Trust, United Kingdom, 5Department of Intensive Care Medicine, Kuopio University Hospital, Finland, 6Department of Critical Care Medicine, Auckland City Hospital, New Zealand, 7Department of Medicine, McMaster University, Canada, 8Department of Anaesthesiology and Intensive Care, Helsingborg Hospital, Sweden, 9 Department of Surgical Sciences and Integrated Diagnostics, IRCCS San Martino, Italy, 10University of Groningen, Department of Critical Care, University Medical Center, Netherland, 11Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Norway, 12Department of Anaesthesia and Intensive Care, Landspitali, Iceland Purpose: To describe the prevalence of, risk factors for, and prognostic importance of gastrointestinal (GI) bleeding and use of acid suppressants in acutely ill adult intensive care patients. Methods: We included adults without GI bleeding who were acutely admitted to the intensive care unit (ICU) during a 7-day period. The primary outcome was clinically important GI bleeding in ICU, and the analyses included estimations of baseline risk factors and potential associations with 90-day mortality. Results: A total of 1034 patients in 97 ICUs in 11 countries were included. Clinically important GI bleeding occurred in 2.6% (95% confidence interval 1.6–3.6%) of patients. The following variables at ICU admission were independently associated with clinically important GI bleeding: 3 or more co-existing diseases (odds ratio 8.9, 2.7–28.8), co-existing liver disease (7.6, 3.3–17.6), use of renal replacement therapy (6.9, 2.7–17.5), co-existing coagulopathy (5.2, 2.3–11.8), acute (4.2, 1.7–10.2), use of acid suppressants (3.6, 1.3– 10.2), and higher organ failure score (1.4, 1.2–1.5). In ICU, 73% (71–76%) of patients received acid suppressants; most received proton pump inhibitors. In patients with clinically important GI bleeding, crude and adjusted odds for mortality were 3.7 (1.7–8.0) and 1.7 (0.7–4.3), respectively. Conclusions: In ICU patients clinically important GI bleeding is rare, and acid suppressants are frequently used. Co-existing diseases, liver failure, coagulopathy, and organ failures are the main risk factors for GI bleeding. Clinically important GI bleeding may be associated with 90-day mortality, but confounding explains some of this association.

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AP-02 Familiarity and genetic risk factors of acute kidney injury Martin Ingi Sigurdsson1, Snaevar Sigurdsson2, Thorir Einarson Long3, Olafur Skuli Indridason3,4, Gisli Heimir Sigurdsson3,5 1 Brigham and Women’s Hospital/Harvard Medical School, United States of America, 2DeCode Genetics, Iceland, 3faculty of Medicine, University of Iceland, Iceland, 4Division of Nephrology, Landspitali University Hopital, Iceland, 5Department of Anesthesia and Intensive Care, Landspitali University Hospital, Iceland Introduction: Acute Kidney Injury (AKI) is associated with high mortality and morbidity. We utilized an unique genealogy database and extensive genotyping on the Icelandic population to study the familiarity of AKI and perform a genome-wide association study (GWAS) to identify risk alleles for AKI. Methods: We reviewed all serum creatinine (SCr) measurements at Landspitali University Hospital serving the vast majority of Icelandic population over 20 years. For every individual with available SCr measurements, we identified the highest SCr value. a baseline SCr within the preceding 6 months and defined AKI as highest/ baseline SCr > 1.5. We excluded patients with disease known to cause AKI. We estimated familiarity comparing the risk of AKI in 1–5th degree relatives of AKI patients compared to 1000 random populations. We performed a case-control GWAS of AKI, using either measured or imputed genotypes. Results: A total of 12.807 individuals had AKI. There was a significant familiarity signal, with 1st-degree relative risk ratio (RR) of 1.21 2nd-degree relative RR of 1.08, 3rd-degree relative RR of 1.12 (P < 0.001 for all). The signal was stronger for the most severe AKI (highest/baseline SCR>3.0), where 1st-degree relative RR was 1.26 (P = 0.006), 2nd-degree relative RR was 1.12 (P = 0.067) and 3rd-degree relative RR was 1.11 (P = 0.06). The GWAS identified


20 O7-02 A 26-weeks pregnant woman with Legionella pneumonia developing ARDS: a case report Hanne Helene Johnsen, Reidun Fosby, Signe Søvik Akershus University Hospital, Norway Introduction: Infection with Legionella pneumophila in pregnancy is a rare and serious condition. We present a case with favourable outcome for both mother and fetus. Case report: A 30-year-old woman at 26 weeks gestation presented with a 2-day story of fever starting during a hotel stay in Southern-Europe. She had a temperature of 38.9°C, tachycardia, tachypnoea, leucocytosis, PaO2 on room air 10.97 kPa and PaCO2 4.42 kPa. Chest X-ray showed a large infiltrate in the right lung base. Fetal monitoring was normal. Urinary antigen was positive for L. pneumophila and intravenous azithromycin was commenced. Non-invasive ventilation was initiated. Patient PaO2 remained acceptable, but at the cost of increasing respiratory work. Invasive ventilation improved the hypoxemia, but the next day the patient’s condition deteriorated further to PaO2/FiO2 = 14. Transfer to a tertiary centre for possible ECMO was arranged. On Bilevel ventilation mode, FiO2 could be reduced from 0.9 to 0.6 within 24 h. Daily fetal monitoring and growth was normal. The patient was extubated after 11 days and discharged after 20 days. At 40 weeks gestation, she delivered a healthy infant. Discussion: Improved diagnostic methods and more potent therapies has reduced mortality in community-aquired legionellosis to < 10%. Legionella is important to consider in pregnant patients presenting with acute pneumonia. Treatment of the pregnant patient with Legionella is similar to that of the non-pregnant patient, while maintaining good fetal monitoring and prevention of premature delivery. Close collaboration between the obstetrician and intensivist is essential. A good outcome is possible with early and adapted treatment.

O7-03 Fatal post partum cerebral venous sinus thrombosis and subdural haematoma – a case report Noora Marjaana Ruotinen, Elina Ruth Johanna P€alvim€aki University Hospital of Helsinki, Finland

Headache is very common during the postpartum period. Approximately 50–75% of the cases are caused by benign primary headache disorders. Cerebral venous sinus thrombosis is a rare but potentially devastating cause of postpartum headache. It presents with a wide range of nonspecific symptoms and clinical manifestations and has a multifactorial background. We present the case of a puerperal patient with an accidental dural puncture during labour analgesia and subsequent postural headache. An epidural blood patch was performed on the third postpartum day, and it provided effective relief. She was discharged on the fourth postpartum day, but the symptoms reappeared the same evening. After contacting the hospital via telephone on the fifth postpartum day she did not seek further medical attention. Three days later she convulsed and lost consciousness. Examination at the emergency department revealed extensive cerebral venous sinus thrombosis, subdural haematoma and ischaemic lesions. Life-saving decompressive hemicraniectomy and evacuation of the haematoma were performed immediately, but the patient did not regain consciousness. Despite intensive

treatment, her condition deteriorated and she died due to the complications of cerebral venous sinus thrombosis and subdural haematoma. A heterozygous factor V Leiden mutation was diagnosed postmortem. Postpartum headache represents a true diagnostic dilemma. We want to urge physicians to keep in mind this rare but potentially fatal cause of postpartum headache and emphasize the importance of careful clinical evaluation and the ensuing follow up.

O7-04 Need for intensive care for obstetric patients in Turku University Hospital and in Central Finland Central Hospital 2009–2013 Eeva Kaarina Kainiemi1, Leena Lavonen2 Turku University Hospital, Finland, 2Finland Central Hospital, Finland

1

Introduction: Although maternal mortality rate in Finland is very low, there is still serious illness and need for intensive care among parturients. The objective of this study was to determine the indications and clinical characteristics of the obstetric patients treated in intensive care units (ICU) in Turku University Hospital (TYKS) and in Central Finland Central Hospital Jyv€askyl€a (KSKS). Methods: Obstetric ICU admissions over 2009–2013 were analyzed retrospectively. Also the number of long-time observed obstetric patients were analyzed. Results: The number of deliveries was altogether 35,781. The total amount of obstetric ICU admissions was 14 in TYKS and 46 in KSKS. The mean maternal age of patients treated in the ICU was 34.8 in TYKS and 31.3 in KSKS. The most common indications for the ICU admission in TYKS and in KSKS were obstetric haemorrhage (50%, 17.4%) and hypertensive disorders (31.4%, 82.6%) respectively. The mean Apache II and Tiss scores were 11 and 28.6 in TYKS and 6.1 and 16.6 in KSKS. Conclusions: Postpartum haemorrhage and pregnancy-associated hypertension were the most common causes of admission to the ICU. The smaller amount of obstetric ICU admissions in TYKS is probably associated with greater number of critically ill obstetric patients treated in labour ward. Depending on the local circumstances, some of the critically ill obstetric patients can be treated in the labour ward, too.

O7-05 The use of magnesium sulphate for the prophylaxis of eclampsia in parturients with severe pre-eclampsia: an audit in Swedish hospitals Lars Bru¨hne NU-sjukv arden, Sweden Introduction: The prophylactic use of magnesium sulphate in parturients with severe pre-eclampsia reduces the risk of seizures, but the NNT is high and there are possible adverse effects. The prophylactic use of magnesium sulphate is recommended in the literature and by obstetric societies, but there are differences in the definition of severe pre-eclampsia, and often further restrictions of the indication. This work aims to find out to which extent parturients with severe pre-eclampsia receive prophylactic treatment with magnesium sulphate in Swedish obstetrical departments, and if there is a correlation to the incidence of eclampsia. Methods: A web-based survey among obstetricians and obstetric anaesthesists in all Swedish obstetrical departments, containing


21 questions on the use of magnesium sulphate in eclampsia and severe pre-eclampsia under 2014, and opinions on its use. A query in the Swedish birth registry about the numbers of parturients, and number of parturients with eclampsia, per obstetrical department under 2014. Results: The survey has not been carried out yet. It is expected that recommendations for the prophylactic use of magnesium sulphate are not followed in all obstetrical departments. One reason might be difficulties in implementing monitoring to avoid severe adverse effects. There might be an association between nonadherence to the recommendations and the incidence of eclampsia. Conclusions: Adherence to recommendations for the prophylactic use of magnesium sulphate is expected to be suboptimal. A checklist defining the indications more exactly might contribute to better adherence to the recommendations.

O7-06 Chronic kidney disease and pregnancy. a case report Vasti Martinez, Ulla Bang Aarhus University Hospital, Denmark Introduction: Chronic kidney disease (CKD) in pregnancy is uncommon, occurring in 0.03–0.12% of all pregnancies. Moderate or stage 3 CKD in pregnancy (serum creatinine 124–220 mmol/l, GFR Glomerular filtration rate 30-59 ml/kg/1.73 m²) increases maternal-fetal morbidity and mortality. Irreversible worsening of the renal function, preeclampsia, restricted intrauterine growth and premature delivery are all common related complications. Method: Case report.This case illustrates the above mentioned maternal-fetal complications presented in a 29 years old patient who became pregnant in CKD stage 3. From 15th weeks of pregnancy her renal function deteriorated and reached to end stage function at 24th week of pregnancy. Concomitant symptoms of preeclampsia and severe fetal growth restriction led to the decision to perform a caesarean section at 26th week of pregnancy. Shortly after delivery she developed critical high blood pressure and HELLP. Hemodialysis had to be initiated and she is awaiting renal transplantation. Conclusions: The negative impact of pregnancy on renal function and the high risk of maternal-fetal complications is a challenge for the anaesthetist and the multidisciplinary team which is required in the management of pregnant patients with severe CKD.

Methods: Data from all missions in the period 01.06.2010– 01.06.2014 were drawn from databases. Reason for mission, severity of injury, interventions and on-scene time were retrospectively analysed. Missions regarding violence or accidents with nottrapped patients having life-threatening injuries were included. Univariate and forward stepwise multiple regression analyses were done to find relationships between specific interventions and onscene time. Interventions were considered associated with on-scene time if P < 0.05. Results: In the period 8192 missions were registered; 635 missions were excluded due to missing data. Of the remaining 7557 missions 1788 fulfilled the inclusion criteria. The interventions intubation (P < 0.01), bag mask ventilation (P < 0.01), spine board (P < 0.01), chest compressions (P < 0.01), suction (P < 0.05) and intraosseous cannula placement (P < 0.05) were found positively associated with on-scene time. Intraosseous cannula placement is to our experience often preceded by failed attempts of intravenous access, which explains the finding. Of the remaining interventions intubation is categorized as advanced, since this is done only by the mobile emergency care units in our region. Conclusion: In the severely injured trauma patient intubation as well as basic airway management, bag mask ventilation, chest compression and immobilisation are all individually positively associated with on-scene time.

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Free Paper Session 8 – Critical Emergency Medicine Training Program (and more)

O8-02 Clinical findings leading to pre-hospital intubation

O8-01 Pre-hospital interventions and on-scene time

Henrik Bitz Alstrøm1, Niels Egholm Pedersen2, Ann Merete Møller3 1 Department of Anesthesiology, Herlev Hospital, Denmark, 2Danish Institute for Medical Simulation, Capital Region of Denmark, Denmark, 3 Emergency Medical Services, Capital Region of Denmark, Denmark

Henrik Bitz Alstrøm1, Niels Egholm Pedersen2, Ann Merete Møller3 1 Department of Anesthesiology, Herlev Hospital, Denmark, 2Danish Institute for Medical Simulation, Capital Region of Denmark, Denmark, 3 Emergency Medical Services, Capital Region of Denmark, Denmark Background: Numerous pre-hospital interventions have been considered positively associated with on-scene time and worsening the prognosis for the severely injured trauma patient. In the Capital Region of Denmark physician-staffed mobile emergency care units do certain advanced pre-hospital interventions. We investigated the association between their on-scene time and interventions done.

Background: In another study we found intubations done by prehospital emergency physicians on mobile emergency care units in the Capital Region of Denmark to be positively associated with onscene time in treating the severe injured trauma patient. We investigated the clinical findings leading to pre-hospital intubation. Methods: Data from all missions done by the mobile emergency care units in the period 01.06.2010–01.06.2014 were drawn from databases. Included in this descriptive study were missions, where intubation was done pre-hospitally, reason for mission was vio-


22 lence or accident, the patient had life-threatening injuries and was not trapped. Data on GCS, respiration and pain were analysed. In accordance with the literature we define GCS < 9, respiration severely affected or unbearable pain as accepted indications for intubation. Results: In the period 8192 missions were registered; 636 missions were excluded due to missing data. A total of 307 missions fulfilled the criteria; 261 patients had GCS < 9, 214 had respiration severely affected, 2 had unbearable pain, while 191 patients fulfilled more than 1 criteria. In 20 patients none of these clinical findings were recorded. Of these 20 patients 14 had head lesions, and 3 had multiple lesions. All these 17 patients had GCS between 8 and 14. Finally 3 patients had a threatened airway due to burns or strangulation. Conclusion: We conclude that pre-hospital intubations done by emergency physicians in the Capital Region of Denmark are done on the well accepted indications GCS < 9, severe affected respiration or unbearable pain.

Results: The SOP consists of a single sheet divided into pre-intubation preparedness, a 13-item equipment checklist, and a plan for unexpected difficult airway. Conclusion: Based upon available literature and experience with SOP and checklists in other areas, in our hospital and other services, there seems to be good reason for implementing one for outof-theatre tracheal intubation. We think our approach will improve patient safety. References: [1] Bowles TM et al. Brit J Anaesth 2011; 107: 687–92. [2] Woodall N et al. Anaesthesia 2011; 66 (Suppl. 2): 27–33. [3] Sherren PB et al. SJTREM 2014; 22: 41. ~ et al. Acta Anaesth Scand 2010; 54: 1179–84. [4] Thomassen A

O8-04 Coding practice of different Mobile Emergency Care Units in the Region of Southern Denmark Rico Frederik Schou, Stine Thorhauge Zwisler, Anne Craveiro Brøchner University Hospital of Odense, Denmark

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O8-03 Development of a Standard Operating Procedure and checklist for out-of-theatre tracheal intubation Espen Hope Nygaard, Signe Søvik Akershus University Hospital, Norway Introduction: Tracheal intubation outside the operating theatre is frequently performed in critically ill patients with deranged physiology and a high risk of hypoxia and cardiovascular collapse. These situations occur unpredictably, out of hours, often with relatively junior staff (1). Out-of theatre tracheal intubation carry high risk, the incidence of events leading to death or brain damage being 30- and 60-fold in the ED and ICU respectively compared to in the OR (2). Standardized equipment preparations and checklists limit human error, improve team communication, and liberate extra bandwidth to maintain situational awareness and facilitate focus on patient care (3). Checklists have been effective in various medical fields (4). Methods: Based on a non-systematical literature search for checklists and SOPs from prehospital, military and in-hospital settings, we developed an intubation checklist suited for a large university hospital.

Introduction: In the Region of Southern Denmark several anesthesiologist-manned Mobile Emergency Care Units (MECU) take part in the prehospital response to both medical and surgical emergencies. Number of missions per day, experience of anesthesiologist, and geography differs between the MECUs and the aim of our study was to evaluate differences of the post-mission coding of the most severely ill patients between the MECUs in different settings in Odense and Svendborg. Methods: The study was a retrospective database study including missions during a four-year period 2010–2013 from both MECUs. Assuming intubation is performed only at life-threatening situations, we looked into all missions where intubation was performed and evaluated if the mission was coded as lifesaving. The relative risk of not having coded correctly according to this was compared between the two MECUs with v2 test (statistic significance set at P < 0.05). Results: A total of 875 patients were intubated during the fouryear period, 653 in Odense and 222 in Svendborg. 140 of the patients that had intubation performed were not coded as life-saving in Odense, in Svendborg a total of 52 were erroneously coded. When comparing these numbers for the 2 MECUs, we found no difference in the coding with a relative risk of 1.1 (confidence interval 0.8–1.5) for coding erroneously (P = 0.5). Conclusion: This study concludes intercomparability of coding practice between the two MECUs in the Region of Southern Denmark and thus further comparative studies can be conducted.

O8-05 Can implementation of a novel standard operating procedure increase the proportion of treat-and-leave decisions? – a quality control study in an anaesthetist-staffed EMS Rikke Mærkedahl, Thomas Dissing Pre-hospital Medical Services, The Central Denmark Region, Denmark Introduction: Increasing the proportion of pre-hospital “treat-and leave”decisions may enhance the cost-effectiveness of physicianstaffed pre-hospital emergency medical services. Implementing standard operating procedures (SOPs) can change pre-hospital critical care anaesthetists’ behaviour [Rogn as et al]. The objectives of this study were to evaluate whether the development and implementa-


23 tion of an SOP for “treat-and leave”decisions in certain groups of patients could increase the “treat-and leave”rates and to identify potential intra-regional variations in the “treat-and leave”rates. Methods: The Central Denmark Region (1.3 million citizens) has 9 anaesthetist-staffed rapid response vehicles (RRVs). We introduced a “treat-and leave” SOP in two rural RRVs and calculated pre- and post-implementation “treat-and leave”-rates. We also compared the rural pre-and post-implementation “treat-and-leave”rates with the “treat-and leave”rates from the RRV covering the largest city in the region. Results: The implementation of the SOP in the two rural RRVs did not impact the “treat-and leave”rates (13.01% vs. 13.75% P = 0.62). The urban RRV had a significantly higher “treat-andleave”rate than the rural RRVs both before and after the implementation of the SOP (Period 1: 17.6% vs. 13.01%, P < 0.05, Period 2: 13.75% vs. 20.73% P < 0.05). Conclusion: The implementation of an SOP for “treat-andleave”decisions in certain groups of patients did not significantly increase the pre-hospital “treat-and-leave”rates. There are significant intra-regional variations in these rates. We will conduct further studies into why the SOP did not have an impact and into the differences in “treat-and-leave”rates between different RRVs in our region.

O8-06 Long-term effects of a physician-manned helicopter on trauma patients Kamilia Funder1, Lars Simon Rasmussen1, Nicolai Lohse2, Rasmus Hesselfeldt1, Volkert Siersma3, Jacob Steinmetz1 1 Copenhagen University Hospital, Rigshospitalet, Denmark, 2 Copenhagen University Hospital, Hvidovre, Denmark, 3University of Copenhagen, Denmark Introduction: The first Danish Helicopter Emergency Medical Service (HEMS) was introduced May 1st 2010. The implementation was associated with lower 30-day mortality in severely injured patients. The aim of this study was to assess the long-term effects of HEMS on labour market affiliation and mortality of trauma patients. Methods: Prospective, observational study with a maximum follow-up time of 4.5 years. Trauma patients from a 5-month period prior to the implementation of HEMS (pre-HEMS) were compared with patients from the first 12 months after implementation (postHEMS). All analyses were adjusted for sex, age and Injury Severity Score. Results: Of the total 1790 patients, 1172 (n = 297 pre-HEMS and n = 875 post-HEMS) were eligible for labour market analyses. Incidence rate of involuntary early retirement or death was 2.4 per 100 person-years pre-HEMS and 2.0 post-HEMS (P = 0.12), Hazard Ratio (HR) = 0.76 (95% confidence interval (CI) 0.44–1.29; P = 0.30) (primary endpoint). The HR of premature labour market exit was 0.79 (95% CI 0.44–1.43; P = 0.43). The prevalence of reduced work ability was 21.4% vs. 17.7%, odds ratio (OR) = 0.78 (CI 0.53–1.14; P = 0.20). The proportion of patients on social transfer payments at least half the time (follow-up period) was 14.9% (IQR 1.3–67.3) vs. 11.5% (IQR 0.0–48.7), OR 0.68 (CI 0.49–0.96; P = 0.03). HR for mortality was 0.92 (CI 0.62–1.35; P = 0.66). Conclusion: The implementation of HEMS was associated with a significant reduction in time on social transfer payments. No signif-

icant difference was found in involuntary early retirement rate, long-term mortality, or work ability.

O8-07 Prehospital spinal immobilization of trauma patients with cervical collar and spineboard based on trauma mechanics and patients0 specific complaints is justified Henriette Nelsson1, Line Parst Sørensen2, Jørgen Fisker3, Søren Mikkelsen2 1 University of Southern Denmark, Denmark, 2Dpt. Anaesthesiol. Intens. Care Med.., Odense University Hospital, Denmark, 3Dept. Anaesthesiology, Lillebaelt Hospital, Denmark Introduction: Based on a combination of trauma mechanics and patient’s complaints, prehospital spinal immobilization using spineboard and cervical collar is usually applied in trauma patients suspected of having a fractured spine. Several disadvantages have been ascribed to the use of such devices, particularly airway compromise, pressure ulcers, concealment of neck injuries or reduced jugular venous return. In order to investigate whether applying spinal immobilization devices is a futile measure or is justified by the actual findings of fractures in the spine, all patients in whom prehospital spinal immobilization was carried out over a period of four years were reviewed. Methods: The medical records of all patients immobilized from January 2010 to December 2013 were retrieved. Each patient was assessed for the presence of a spinal fracture or other spinal injury occurring as a result of the trauma. In any patient experiencing spinal fracture it was registered whether the injury required operation. Injury Severity Score was calculated in all patients. Results: A total of 930 cases were included. In 83 (8.9%), the trauma resulted in one or more fracture of the spine (total 139 fractures), 26 (2.8%) requiring operations. A further 20 (2.2%) patients had other spinal injuries. ISS score was significantly higher in immobilized patients having spinal fractures than in patients without spinal fractures. Conclusions: On the basis of the actual number of patients being immobilized prehospitally indeed suffering from fractures, the practice of immobilizing patients based on the combination of knowledge of trauma mechanics and patients’ complaints seems justified.

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24 O8-08 A national trauma system? A retrospective assessment of the flow of severely injured patients in Norway 2013 Torben Wisborg1, Eirin N Ellensen2, Ida Svege1, Trond Dehli3 1 Oslo University Hospital, Norway, 2Norwegian Air Ambulance Foundation, Norway, 3University Hospital of Northern Norway, Norway Introduction: A novel Norwegian trauma system was proposed to the regional health trusts in 2007, and implemented during the period 2008–2011 after regional adaptations. As Norway still has no central trauma registry, the actual disposition of patients with severe injuries is unknown. We wanted to collect information from local trauma registries to describe patients and destinations. Methods: A survey was done to all hospitals caring for severely injured, collecting data from all hospitals with local trauma registries. Patients were analysed at hospital level, i.e. trauma centres or acute care hospitals with trauma function. Patients were classified as severely injured if Injury Severity Score (ISS) was above 15. Results: Three trauma centres (75% of all) and 17 acute care hospitals (53% of all) had complete data for 2013, in total 3535 trauma registry entries (primary admissions only). Severe injuries were found in 604 patients, of whom 249 (41%) were primarily admitted to acute care hospitals with trauma function. Seventy-one patients (12% of all severely injured) were subsequently transferred to a trauma centre. Two trauma centres and seven acute care hospitals screened for undertriage (severely injured not received by trauma team) and found an undertriage of 53 of 604 (9%), with similar frequencies at both hospital levels. Conclusion: This survey shows that approximately one third of all severely injured in Norway are admitted to – and receives definitive treatment in – acute care hospitals with trauma function, and not trauma centres. The rate of undertriage is above international recommendations.

Free Paper Session 9 – Obstetric Anaesthesaia O9-01 Emergency Caesarean Hysterectomy, a ten year retrospective review in KK Women’s and Children’s Hospital, Singapore

Conclusions: Incidence is 0.13 : 1000 deliveries. Main cause is placenta accreta vera. Main risk factor is a previous uterine procedure. Main complications were blood transfusion, intensive care unit admission and disseminated intravascular coagulation.

O9-02 Neuroaxial blockade for combined operation for internal herniation after gastric bypass operation and C-section Lars Møller Pedersen, Inge Marie Poulsen, Kirsten Riis Andreasen, Nicolai Bang Foss Hvidovre Hospital, Denmark Introduction: Roux-en-Y gastric bypass operation (RYGB) is an effective treatment of obesity. A well-known complication is internal herniation of the intestine through iatrogenic mesenteric defects ultimately causing ileus and incarceration. Weight loss after RYGB increases female fertility and also the risk of internal herniation. In late pregnancy, surgery for internal herniation after RYGB is sometimes carried out in conjunction with cesarean section (CS). Previous reports of this joint venture operation have focused mainly on diagnostic and operative challenges with little attention to anaesthesia. Due to the high incision, general anaesthesia is probably often chosen. Methods: With bariatric and obstetric surgery at our institution, we offer operation for internal herniation in combination with CS, often carried out in a neuroaxial blockade. In this retrospective survey, patients from a 18-month period were reviewed to determine choice of anaesthesia and the rate of conversion from regional to general anaesthesia. Results: Of 11 patients 7 completed the operation in neuroaxial blockade (1 spinal, 6 combined spinal/epidural) and 4 in general anaesthesia. Intra-operative conversion in anaesthetic technique was found in one patient exhibiting hyperventilation and chest thightness. Conclusions: Due to the combined risk of aspiration and difficult airway, CS patients should be anaesthesized with the use of a neuroaxial technique. We have demonstrated that this is possible in case of combined surgery with repair of internal herniation after RYGB. Thus, surgical teams should plan for handling these complicated patients in regional anaesthesia. Future research from our side will determine the degree of preoperative hypovolemia.

Mukesh Kumar Shah KK Women’s and Children’s Hospital, Singapore Introduction: The incidence of caesarean hysterectomy in our institution is expected to rise with the rising incidence of caesarean section, placenta praevia and accreta. It is usually done electively due to lesser morbidity. For those done as emergency, I would like to define their incidence, causes, risk and confounding factors, and complications. Methods: Cases were retrieved from computerised medical records from July 2003 to June 2013 using the code for Caesarean Section + Hysterectomy, selecting emergency cases only. Causes, risk and confounding factors, and complications were recorded. Results: 16 cases of emergency caesarean hysterectomies gave an incidence of 0.13 : 1000 deliveries. Main cause was placenta accreta vera (13/16, 10/13 had placenta praevia major). Placenta increta was present in 2/16 (one of which had placenta praevia major). Main risk factor was a previous uterine procedure (12/16). Gestational age at delivery was less than 34 weeks in 7/16. Uterine contractions at the time of delivery were present in 10/16. Main complications were blood transfusion, intensive care unit admission and disseminated intravascular coagulation.

O9-03 Auditory function following post dural puncture headache treated with epidural blood patch A long-term follow-up of parturients Bijan Darvish1, Gunnar Dahlgren2, Lars Irestedt1, Anders Magnuson3, Cales M€oller4, Anil Gupta1 1 Karolinska University Hospital, Sweden, 2Capio St G€orans Hospital, € Sweden, 3Orebro University, Sweden, 4School of Medicine and Health Science, Institute of Disability Research, Sweden Background: Epidural analgesia is commonly used for pain management during labor. Sometimes, accidental dural puncture (ADP) occurs causing severely debilitating headache, which may be associated with transient hearing loss. We investigated if auditory function may be impaired several years after ADP treated with epidural blood patch (EBP). Methods: Sixty women (ADP group) without documented hearing disability, who received EBP following ADP during labor between the years 2005–2011 were investigated in 2013 for auditory func-


25 tion using the following tests: otoscopic examination, tympanometry, pure tone audiometry and transient evoked otoacoustic emissions. Additionally, they responded to a questionnaire, the Speech, Spatial and Qualities (SSQ) of hearing, concerning perceived hearing impairment. The results were compared to a control group of 20 healthy, non-pregnant women in the same age group. Results: The audiometric test battery was performed 5.2 (1.9) years after delivery. No significant differences were found between the ADP and the control groups in tympanometry or otoacoustic emissions. Pure tone audiometry revealed a significant but small (< 5 dB) difference between the ADP and control groups (P < 0.05). The ability to hear speech in noise as measured by SSQ was significantly reduced in the ADP group compared to the control group (P < 0.05). Conclusions: A minor hearing loss was detected in the ADP group compared to the control group in pure tone audiometry and during speech in noise component several years after accidental dural puncture treated with an epidural blood patch. This small but persistent hearing loss has minor clinical significance.

O9-04 Bacterial meningitis – who is the guilty? Diogo Bastos Martins, Elisabete Aquino Centro Hospitalar Lisboa Ocidental, Portugal The use of neuraxial blockade techniques as become routine for labor analgesia. The complications of those techniques are well known and can range from easy controlled events to dramatic situations that endanger the lives of pregnant women. The infectious complications like bacterial meningitis are extremely rare and several retrospective studies have estimated this incidence as lower than 0.05%. To illustrate those situations we present a case report of a term pregnant woman who was made neuraxial analgesia. This is a woman with no relevant medical history but had membranes rupture for about 12 h long. It was proposed an epidural/spinal technique that was apparently performed without complications. On the day following the delivery the women become prostrate with severe headache, photophobia with meningeal signs and fever, so it was placed a provisional diagnosis of meningitis and empirical antibiotic therapy was initiated. Three days after delivery, due to lack of significant clinical improvement a lumbar puncture was made with cerebrospinal fluid collection, which was clearly purulent, for biochemical and microbiological studies. Further investigation with the patient revealed that the woman had headaches and 37°C temperature before hospitalizations for childbirth. In order to clarify the origin of this infection – neuraxial technique vs. previous infection vs. prolonged membranes rupture – we waited for bacterial cultures results. Despite the fact that is a “police case” is important to ensure that neuraxial blockade techniques are made in completely aseptic conditions to prevent infectious complications.

O9-05 HELLP Syndrome: anesthetic implications in emergency cesarean delivery Claudia Sofia Nunes Mesquita1, Fernando Manso2 1 Hospital Fernando Fonseca, Portugal, 2Hospital Prof. Dr. Fernando Fonseca, Portugal Background: HELLP syndrome poses a significant anesthetic challenge. Onset is usually rapid, increasing probability of emergent delivery. Preeclampsia is a risk factor. Activation of vascular endothelium and of platelets, hemolysis and liver damage are the basic pathophysiological features.

Case Report: A 25-year-old woman was admitted at 32 weeks’ gestation due to vaginal hemorrhage and marginal placental abruption. She had a history of gestational hypertension. Blood analysis was normal. Fetal wellbeing was confirmed. Two days after admission, she developed severe preeclampsia. Blood laboratory data showed thrombocytopenia, elevated liver enzymes and acute renal failure (ARF). The obstetrician suggested HELLP syndrome. An emergency cesarean delivery was scheduled. After pre-oxygenation, general anesthesia (GA) was induced. Tracheal intubation was performed with difficulty. Systolic blood pressure was controlled with labetalol. A live-born infant was delivered (APGAR1: 4). Intravenous magnesium sulfate was given. The cesarean delivery proceeded without an event. Estimated blood loss was 1000 ml and she was transfused with blood components. The patient was transferred to the ICU with an uneventful recovery. Discussion: Placental abruption associated with the HELLP syndrome increases the risk of disseminated intravascular coagulation, respiratory failure and ARF. Before 34 weeks’ gestation, immediate cesarean section should be performed if the maternal condition worsens or signs of intrauterine fetal distress occur. The presence of coagulopathy precludes regional anesthesia. GA may cause exaggerated cardiovascular response to intubation leading to cerebral hemorrhage, cardiovascular decompensation and impairment of uteroplacental blood flow. Prematurity, intrauterine growth restriction, and intraventricular hemorrhage are the leading causes of neonatal death.

O9-06 Anesthetic challenge in obstetrics: emergent postpartum hysterectomy Claudia Sofia Nunes Mesquita1, Fernando Manso2 1 Hospital Fernando Fonseca, Portugal, 2Hospital Prof. Dr. Fernando Fonseca, Portugal Background: Postpartum hemorrhage (PPH) is an obstetric complication with important morbidity and mortality (1–5%). The multiparity, abnormal placentation, instrumented delivery and uterine atony are risk factors. Emergent postpartum hysterectomy (EPH) is performed at time or within 24 h of delivery in severe uterine hemorrhage that cannot be controlled by conservative measures. Case Report: A 32 years old pregnant was admitted to an obstetric clinic for delivery in established spontaneous labour at 39 weeks gestation. No medical history. Vacuum-assisted vaginal delivery was performed without complications. Revision of uterine cavity was done. Uterus didelphys and isthmus left heterogeneous image was evidenced in postpartum ultrasound. Six hours after delivery was proposal for exploratory laparotomy due to abundant hemorrhage and hypotension, without fluid response (Hb : 6.3 g/dL). Rapid sequence induction of general anesthesia (GA) was performed after adequate pre-oxygenation. Intubation was achieved without desaturation. During surgery was identified a hypotonic uterus, a extensive pelvic hematoma (covering the broad ligaments and infundibulopelvic fold) and a hemorrhagic suffusion bladder. Obstetric team decided to hold total hysterectomy and left salpingo-oophorectomy. Hemodynamic stability and urine output was maintained. Packed red blood cells, fresh frozen plasma, platelets and fibrino-


26 gen was transfused. She was extubated awake at the end of surgical procedure. Discussion: The hemorrhagic shock, disseminated intravascular coagulation and renal, hepatic or respiratory failure are the major complications of PPH. The anesthesiologist should keep in mind the importance of fluid resuscitation and anticipate a massive transfusion scenario, minimizing its effects (hypothermia, acidosis and coagulopathy). GA is recommended.

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Free Paper Session 10 – Emergency Medicine I O10-01 From in-situ simulation to SOP development Per P. Bredmose, Stephen Sollid Norwegian Air Ambulance Foundation, Norway We are conducting a one year prospective trial of in situ simulation for on-call Helicopter Emergency Medical Service (HEMS) crews (HEMS-physician,crewmember and pilot). Experiences gained from these scenarios have influenced standard operating procedures (SOP) development. We therefor propose, that low fidelity in situ simulation can not only be an effective tool for training crews, but also contribute to SOP development as a probing tool to gather experience with treatment and patient management strategies. Methods: Eleven HEMS bases in Norway are included in the prospective trial. Generic goals for the simulation exercises are: correct management of the patient, rational use of all members of the team and equipment and team safety on scene. Each simulation exercise is followed by a debriefing of the crew where the facilitator records important learning points that could be used to improve SOPs. Results: An SOP for the “Management of a patient with potential symptoms of Ebola virus disease”was developed as a direct result of experiences from a simulation scenario and the “Prehospital RSI”and “Difficult airway algorithm”was improved following another scnario. Furthermore deficiencies among all crew members in the knowledge of use of medical equipment was discovered and addressed. Areas of improvement of the weekly equipment checks were identified. Various needs for additional crew education has been discovered after simulation. Conclusion: Low fidelity simulation with standardized scenarios for on call HEMS crews is an effective way test new and existing treatment and management strategies to improve and develop new and better SOPs.

O10-02 Implementation of in situ simulation for all HEMS bases in Norway: challenges and solutions Per P. Bredmose, Stephen Sollid Norwegian Air Ambulance Foundation, Norway In-situ training during on-call duty can be a time-effective way to give pre-hospital personnel as a team. We are conducting a one year prospective trial on all helicopter emergency medical service (HEMS) bases in Norway on the implementation of a simulation based in-situ training concept for on-call HEMS crews. Before the project was initiated we attempted to identify potential challenges in the project and suggest initial solutions to these challenges. Methods: Eleven bases in Norway are included in the project. On each HEMS base, one or two HEMS physicians are trained as simulation facilitators in a common generic course (EUSIM), tailored to prehospital care. During this course a structured group interviews was performed with all the HEMS physicians being trained as facilitators, focusing on expected challenges and their solutions. Results: Challenges identified were: Variation among crews in attitude to this form of training, missions before or during simulation training, lack of facilitators, getting bored of simulation training over time, feeling that the training does not suit all members of the crew Solutions suggested were: Keeping time consumption to a reasonable number, train maximum once a week (HEMS crews can be on-call for up to one week), making training scenarios as variable as possible, changes scenarios frequently, making sure that no-one undertakes the same scenario. Discussion: Weekly simulation provided a unique opportunity to train the whole crew in medical matters, team matters and decision-making. The results from our study will show if the suggested solutions for itation challenges were effective.

O10-03 Epidemiology and aetiology of unconsciousness in prehospital non-trauma patients in an urban setting

Johannes Bj€orkman1, Juhana Hallikainen2, Klaus Olkkola2, Tom Silfvast2 1 Helsinki University, Finland, 2Helsinki University and Helsinki University Hospital, Finland

Introduction: There are limited data on the epidemiology and aetiology of non-traumatic loss of consciousness in patients in the Emergency Department, and this high-risk patient group is even less described in the prehospital field. The aim of this study was to determine the epidemiology and aetiology of non-traumatic unconsciousness among the patients treated by an urban emergency medical service (EMS) system in Finland. Methods: Data of all emergency calls not related to trauma in an urban EMS system southern Finland during 2012 was analysed. The inclusion criterion in this study was unconsciousness as identified from the EMS run sheets. Diagnoses made in the receiving facility were crosschecked with the data. Results: During the study period, the EMS was alerted to 22,184 emergency calls. Of these, 307 calls met the inclusion criteria. The included patients could be categorized into four groups: seizures (32%), diabetes (24%), intoxication (17%), and unconsciousness with no other obvious or specific cause (27%). The overall mortality of the study population was 8%.


27 Conclusions: Of all EMS calls, unconscious patients represented 1.4% of all patients, but the mortality in those who remained unconscious during the prehospital phase was considerable. Unconsciousness was associated with a multitude of aetiologies, of which seizures were the most common. Table. 1. Characteristics of unconscious prehospital patients. Brackets indicate percentages, unless otherwise stated. “Treat-and-leave” refers to patients who. Source: https://www.eventure-online.com/ parthen-uploads/154/SSAI/img1_264866_2uogtd3hGS.png

63% of the cases. The exception was falls, where only 16% of deaths were pre-hospital. (Fig. 1) For all accidents together, the rural areas had a higher share of pre-hospital deaths than the urban areas (52% vs. 41%, P = 0.04). Most injuries occurred at home (50%). Conclusions: The rural areas had a higher injury mortality rate compared to the urban areas and a higher share of pre-hospital deaths. Falls were the most common cause of injury-related deaths. The preventable pre-hospital deaths are an important aim for further studies.

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O10-05 An investigation into morning morality Anne Craveiro Brøchner, Søren Mikkelsen Odense University Hospital, Denmark

O10-04 Fatal injuries in Northern Finland – Pre-Hospital death dominates Lasse Viljam Raatiniemi1,4, Tine Steinvik2, Torben Wisborg2,3, Matti Martikainen4, Janne Liisanantti4, Seppo Alahuhta5, H akon Kv ale Bakke6 1 Lapland Central Hospital, Finland, 2University of Tromsø, Norway, 3 Oslo University Hospital, Norway, 4Oulu University Hospital, Finland, 5 University of Oulu, Finland, 6Helgeland Hospital Trust, Norway Introduction: Injuries cause a high number of life years lost. Rural areas have higher injury mortality rates than urban areas. We aimed to study demographics and possible differences in injuryrelated deaths occurring either in rural, semi-urban or urban municipalities in Northern Finland. Methods: All injury-related deaths in 2007–2011 were identified using The Causes of Death Register maintained by Statistics Finland. Information concerning the deaths was retrieved from death certificates and hospital records. Results: During the study period there were 2915 injury-related deaths. Of these, 1959 met the inclusion criteria. Annual crude mortality rate per 100.000 inhabitants was 77 in rural, 57 in semiurban and 43 in urban municipalities. Mortality rate was significant higher (P < 0.0001) in the rural municipalities. Accidents caused 64% of injury-related deaths. The most common mechanisms for accidents were falls on the same level (49%) and trafficinjuries (19%). The death occurred in the pre-hospital setting in

Introduction: “Morning morality” is a term that describes that humans are more prone to unethical behaviour at some points of the day than other. Physicians, however, are expected to act morally and ethically correct whatever the time of day. The Mobile Emergency Care Unit in Odense, Denmark, is dispatched on the basis of specific criteria and the dispatch is not influenced by the physician manning the MECU. However, the outcome of any run – be it mission aborted, patient accompanied to hospital, patient admitted without physician escort – is at the discretion of the physician. We sought to investigate whether more patients were admitted without physician escort during the night or just before the end of the shift than at other times as a surrogate marker for differences in ethical behaviour. Methods: Over a period of four years, all runs in the MECU, Odense were reviewed. For each run it was registered whether or not the patient was escorted to the hospital by the emergency physician. For each whole hour, the proportion of physician-accompanied runs was compared with the total number of runs. Results: In 18927 runs approximately 50% of the patients were admitted to the hospital. The frequency of escorted patients varied through the day from 11, 4% at noon (12–13 h) to 18% in the early morning hours (3–4 h). This difference proved insignificant. Conclusion: In the MECU in Odense we found no evidence of changes in admission patterns over the day and as such, no evidence of “morning moralities”.


28 O10-07 Implementation of a global open access template for reporting pre-hospital major incident medical management Sabina Fattah1, Kari Milch Agledahl2, Marius Rehn1, Torben Wisborg2 1 Norwegian Air Ambulance Foundation, Norway, 2University of Tromsø, Norway

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O10-06 Reduced admission process times by direct admission of cardiology patients at the emergency department Sohil Equbal Pothiawala1, Nyi Nyi Zaw1, Swee Han Lim1, Paul Chun Yih Lim2, Aaron Sung Lung Wong2, Jack Wei Chieh Tan2, Evelyn Wong1, Terrance Siang Jin Chua2, Marcus Eng Hock Ong1 1 Singapore General Hospital, Singapore, 2National Heart Center, Singapore Introduction: Prolonged waiting times are common in Emergency Departments (ED) worldwide. Traditionally, patients presenting with cardiac complaints to ED at Singapore General Hospital (SGH) were seen by ED physician and then wait for review by oncall cardiologist before admission. The objective was to improve the admission process and evaluate the effect of this new direct admission pathway on ED admission process times. Methods: A joint ED-Cardiology workgroup proposed and implemented a direct admissions pathway. ED specialists were empowered to decide direct admission for stable cases of angina pectoris, heart failure and arrhythmias. But for cases needing a High Dependency or ICU bed, the ED doctor would consult cardiologist oncall to get a bed. Data before implementation (Indirect Admission) was collected from 16 Aug 2014 to 14 Sept 2014 (29 days) and after implementation (Direct Admission) from 15 Sept 2014 to 16 Oct 2014 (32 days). Results: There were 302 cases in Indirect and 303 cases Direct Admission period. The median ED arrival to disposition time decreased significantly from 221 mins (interquartile range [IQR] = 147–308 min) in the Indirect Admission period to 132 min (IQR = 78–187 min) in the Direct Admission period (P < 0.001). Also, the median time to duration of stay in DEM decreased significantly from 365 min (IQR = 244–478 min) to 262 mins (IQR = 186–337; P = 0.001). Conclusion: There was significant reduction in ED arrival to disposition times as well as reduced ED length of stay after implementation of Direct Admission to cardiology in tertiary teaching hospital.

Introduction: We facilitated international clinical and academic experts’ creation of a template for reporting pre-hospital medical management of major incidents. The template was published (1) open access and the online reporting is freely accessible on www.majorincidentreporting.org. To date four reports from Norway, UK, Chile and Finland have been published. This study aimed to identify reporters’ opinions of the feasibility of the template. Methods: Persons who had used or been invited to use the template were interviewed of their experience and opinion of it. Semistructured interviews were conducted and audio recorded. Content was verbatim transcribed and analysed using Grounded Theory methodology. Results: Seven of 12 invited persons participated. The major theme identified was “defining purpose”. The rationale behind each question needs clarification. The resources necessary for filling in reports and clarity regarding the aim and outcome of reporting need to be communicated to users and policy makers. In further dissemination of the template it may be emphasised that others have found it a useful tool. Conclusions: The template offers systematic means for data gathering and a tool for policy makers and managers to improve their systems, but needs some clarification of purpose to attract new reports. Reference: [1] Fattah S, Rehn M, Lockey D et al. A consensus based template for reporting of pre-hospital major incident medical management. Scand J Trauma Resusc Emerg Med 2014; 22: 5.

O10-08 Dispatch precision of advanced prehospital treatment for severely injured trauma victims in Norway – a national study

Torben Wisborg1, Eirin N Ellensen2, Ida Svege1, Trond Dehli3 1 Oslo University Hospital, Norway, 2Norwegian Air Ambulance Foundation, Norway, 3University Hospital of Northern Norway, Norway Introduction: Most studies of severely injured suggest a survival benefit from advanced prehospital treatment. The benefit will depend on disposition of the resources to patients in most need. Anaesthesiologists staff the 18 Helicopter Emergency Medical Services (HEMS) in Norway on duty 24/7/365. National regulations describe indications for the use, but no national dispatch criteria exist, although the use of Norwegian Index for medical emergency assistance is recommended. The precision in dispatch of HEMS for trauma victims is unknown. We wanted to assess the use of HEMS for the severely injured on a national scale in 2013. Methods: A national survey to all hospitals caring for severely injured collected data from all local trauma registries for 2013. Patients were analysed according to hospital level, i.e. trauma centres or acute care hospitals with trauma function. We considered patients with Injury Severity Score (ISS) above 15 severely injured. Results: Three trauma centres (75% of all) and 17 acute care hospitals (53% of all) had complete data for 2013, in total 3535 trauma registry entries (primary admissions only) including 604 victims with an ISS > 15. Of these 604 victims, prehospital anaesthesiolo-


29 gists treated 51%. Sixty percent of the severely injured admitted directly to trauma centres had prehospital advanced treatment, while only 37% of the severely injured admitted primarily to acute care hospitals received advanced prehospital care. Conclusion: Despite national HEMS experience since 1978 and recommendation to use dispatch tools in the emergency dispatch centres, the precision of HEMS disposition is low.

O10-09 Epidemiology of spinal fractures with and without spinal cord injury at Landspıtali in Iceland 2007–2011

Eryun Arna Kristinsdottir1, Halldor Jonsson jr1, Pall Ingvarsson3, Sigrun Knutsdottir4, Kristinn Sigvaldason4 1 Faculty of Medicine, University of Iceland, 2Department of Orthopedics, 3 Department of Rehabilitation, 4Department of Anesthesia and Intensive Care, Landspitali, University Hospital, Iceland Introduction: The aim of this study was gathering epidemiological information on patients admitted to Landspıtali with spinal fractures, with and without spinal cord injury and identify risk factors. Material and Methods: A retrospective review of patients admitted due to spinal fractures during the period 2007–2011 and analysis of causes, age, gender, extent of injury and occurrence of spinal cord injury. Results: Admitted patients with spinal fractures were 487 or 31/ 100.000 inhabitants/year, thereof 42 (9%) with spinal cord injury or 2,7/100.000 inhabitants/year. Average age was 56 years, males were 57%. Falls were the leading cause of spinal fractures (49%) and spinal cord injury (43%). The majority of low falls (< 1 m) were amongst women with the mean age of 77 years. Road traffic accidents caused spinal fractures in 31% of cases and 26% of spinal cord injuries, most often in rural areas (79%). Seatbelts were not used in 20% of car accidents but information was missing on 27%. Sport/leisure accidents caused spinal fractures in 12% of cases whereof horse-riding accidents were the most common (36%). The most common fracture site was at the lumbosacral level (41%). Of those suffering spinal cord injury, 38% had complete injury on admittance and 43% needed a wheelchair at discharge. Conclusions: Spinal fractures lead to spinal cord injury in 9% of patients, most often due to falls, followed by road traffic accidents. Safe roads and better traffic culture is essential to decrease serious road traffic accidents. Further investigation on falls in the elderly is also necessary.

in an artificial trachea. Cuffs were kept inflated at 25 cmH2O. Three mL dyed water was placed above the cuff and leakage recorded under static and dynamic (i.e. 5 cmH2O PEEP alone and positive pressure ventilation plus 5cmH2O PEEP) conditions. At the end of the dynamic experiments, either PEEP was zeroed or the ETTs disconnected. Results: In the static model, leakage flows were 10.8 5.0; 1.6 1.4; 0.04 0.03; 0.06 0.07; and 0.0 0.0 ml/min for respectively the PVCcyl, PVCcon, PUcyl, PUcon and PVCdc cuff (P < 0.001, PVCdc vs. other cuffs). In the dynamic setting, no leakage was detected up to 60 min in any of the studied cuffs. Loss of PEEP and ETT disconnection resulted in immediate dye inflow alongside all cuffs except for the PVCdc (P < 0.001, PVCdc vs. other cuffs). Conclusions: In static conditions, the novel PVCdc outperformed all PVC and PU-cuffed comparator ETTs in preventing leakage. PEEP guaranteed adequate sealing in all studied ETTs. However, only the PVCdc protected against leakage after release of PEEP or ETT disconnection.

O11-02 Incidence of late complications after percutaneous tracheostomy and after oral intubation Benjamin Stage Storm, Erik Waage Nielsen, Knut Dybwik Nordlandssykehuset, Norway Introduction: In large international studies, upper airway related stenosis, granulomas, malasias and laryngeal nerve palsy following percutaneous tracheostomy have an estimated incidence of 6–31%. The incidence following prolonged oral intubation is estimated to 10–22%. We wanted to assess the incidence of complications in our unit.

Free Paper Session 11 – Mechanical Ventilation O11-01 A newly developed endotracheal tube offering ‘pressurised sealing’ outperforms currently available tubes in preventing cuff leakage: a benchtop study Herbert Spapen, Emiel Suys, Wim Stiers, Geertde Smet, Marc Diltoer, Joukede Regt, Patrick M Honore ICU department, University Hospital, Vrije Universiteit, Belgium Introduction: We developed an endotracheal tube (ETT) equipped with 2 polyvinylchloride (PVC) cuffs and a supplementary canal in-between cuffs through which a continuous positive pressure of 5 cmH2O is provided (PVCdc). Methods: We compared the PVCdc with 4 different cuff types [cylindrical PVC, PVCcyl); conical PVC, (PVCcon); cylindrical polyurethane (PU), (PUcyl); and conical PU, (PUcon)]. ETTs were placed

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30 Methods: A retrospective computer assisted combined search of a single unit intensive care patient population. Patient records for the defined period were searched using a predefined search string, identifying those who received invasive mechanical ventilation, split in subgroups by oro-tracheal tube or tracheostomy tube. This search was cross-linked with ICD-10 codes associated with recognized complications (J38, J39, J95, J99, R04.8, S27.5). Results: During the period 1/1/1997–31/12/2013, a total of 32.852 patients stayed at the ICU. 1620 of these received invasive mechanical ventilation. Of these 519 had a tracheostomy, 1109 where orally intubated. Four tracheostomised patients had ICD-10 codes related to complications and no orotracheal intubated patients had ICD-10 codes related to complications. On the background of patients notes, it became clear however, that three of the four patients in the tracheostomised group had their tracheostomy subsequent of the symptomatic airway problem and the 4th patient had her trachoestomy following a post-intubation airway stenosis. Conclusion: Spanning a 17 years period, our study did not show any long term symptomatic upper airway complications following tracheostomy and only one following orotracheal intubation. This contrasts the internationally estimated incidence. Despite some limitations in our study, it might seem like both procedures carry less complications, than stated in the international literature.

O11-03 A multivariable model to predict duration of mechanical ventilation Andrew A. Kramer1, Jack E. Zimmerman2 1 Cerner Corporation, United States of America, 2George Washington University, United States of America Introduction: Mechanical ventilation (MV) is frequent and accounts for a disproportionate amount of intensive care unit (ICU) resource use, particularly when duration is prolonged. The prevalence and high cost of mechanical ventilation have led to the development of multiple processes aimed at reducing its duration. The ability to assess patient factors that influence duration of MV would be useful for assessing the impact of different care processes and comparing the efficiency and cost of MV across ICUs. Methods: A retrospective cohort analysis was carried out that examined physiologic, clinical, diagnostic, and demographic characteristics for 57,203 U.S. ICU patients receiving MV on ICU day one during 2010–2014. The 70 ICUs in this study had installed an APACHE system. A multivariable regression model of the aforementioned factors was usedto predict the duration of MV for patients admitted during 2010–2012, and then validated on patients admitted during 2013–2014. Results: The geometric mean duration of MV was 1.72 days. Physiology as measured by the acute physiology score of APACHE IV was the most influential predictor, followed by diagnosis, emergency surgery, and COPD comorbidity. In the validation data set the mean observed duration of MV was 1.73 days vs. a prediction of 1.81 days (difference = 1.9 h). At the patient level the R2 was 0.233, while across ICUs R2 was 0.723. Conclusions: A predictive model was created to estimate LOMV that proved highly accurate at the ICU level. This model will allow ICUs to benchmark their performance in regard to duration of MV.

O11-04 Cyclic stretch and expression of innate immune effectors in lung epithelial cell lines Harpa Ka´rado´ttir1, Nikhil N Kulkarni1, Thorarinn Gudjonsson1, Gudmundur Hrafn Gudmundsson1, Sigurbergur Karason2 1 University of Iceland, Iceland, 2Landspitali National University Hospital, Iceland Introduction: Ventilator treatment has the inherent risk of causing damage to lung tissue and increase risk of infections. Our aim was to study how cyclical stretch, mimicking ventilator treatment, would affect innate immunity of lung epithelial cells and if their innate immunity could be enhanced during such circumstances. Methods: VA10, a lung epithelial cell line, was placed in Flexcellâ FX-5000TM Tension System where the cells went through cyclic stretch. Further the cells were treated with vitamin D3 and 4-phenyl butyrate (PBA), known inducers of innate immunity. The mRNA and protein expression were examined with qRT-PCR and western blotting, respectively. The cells were stained with specific antibodies and analysed with immunofluorescent microscopy. Results: The cells showed significant changes in gene expression upon cyclic stretch. The pro-inflammatory chemokines/cytokines for IL-8 and IL-1beta were enhanced at mRNA level. While the chemokine CXCL10 (IP10) and toll like receptor 3 (TLR3) were significantly suppressed. The mRNA for the antimicrobial peptide LL37 was suppressed but this effect could be reversed by vitamin D3 and PBA. This counteraction of LL-37 expression was also confirmed at protein level. Conclusion: Novel information of the effect of cyclic stretch on lung epithelial cells was gathered. Epithelial pro-inflammatory signature was induced but surface defenses suppressed. Innate immunity decreased during cyclical stretch but the effect was reversible by adding inducers of innate immunity like vitamin D3. This might have clinical relevance, as the results indicate that the endurance of lung epithelial cells against negative effects of ventilator treatment can be counteracted. Results: The cells showed significant changes in gene expression upon cyclic stretch. The pro-inflammatory chemokines/cytokines for IL-8 and IL-1beta were enhanced at mRNA level. While the chemokine CXCL10 (IP10) and toll like receptor 3 (TLR3) were significantly suppressed. The mRNA for the antimicrobial peptide LL37 was suppressed but this effect could be reversed by vitamin D3 and PBA. This counteraction of LL-37 expression was also confirmed at protein level. Conclusion: Novel information of the effect of cyclic stretch on lung epithelial cells was gathered. Epithelial pro-inflammatory signature was induced but surface defenses suppressed. Innate immunity decreased during cyclical stretch but the effect was reversible by adding inducers of innate immunity like vitamin D3. This might have clinical relevance, as the results indicate that the endurance of lung epithelial cells against negative effects of ventilator treatment can be counteracted.

O11-05 Measured changes in serial dead space during modification of pressure support Nilanjan Dey1, Sebastian Larraza2, Stephen Edward Rees2, Dan Stieper Karbing2, Robert Ravnholt Winding1 1 Regions Hospital Herning, Denmark, 2Aalborg University, Denmark Introduction: Measuring serial dead space (Vds) before and after modification of pressure support (PS) may be necessary to select optimal level of ventilator support. As part of our study for understanding patients’ response to changes in PS, Vds was mea-


31 sured on a breath by breath basis.We present measured changes in Vds due to modification of PS. Methods: The study included 12 patients ventilated on PS. Ethical approval were obtained from the committee of Mid-Jutland, Denmark. Patient or next of kin and general practitioners consent was obtained. Each patient was subjected to a series of up to 2 cm H2O step modifications, beginning with reduction of PS. Each PS level was maintained for 15 min. Airway flow and FeCO2 were continuously measured. VCO2 was determined by synchronizing airway flow and FeCO2 signals. The flow signal was mathematically integrated to determine tidal volume (Vt). The product between volume and FeCO2 determined VCO2. Vds was calculated with Equation 1, and verified by calculating Fowler’s method corrected to rebreathed CO2 from patients’ tubing (Vdf). Vds ¼ Vt-VCO2 =ðfR-(FeCO2 FiCO2 Þ ð1Þ Results: Correlation equations between Vt and serial dead space calculations are shown in Fig. 1. Grey circles represent Vds, and blank circles represent Vdf. The correlation coefficient between both calculations was r = 0.93 (P < 0.001). Conclusion: Vds adequately describes serial dead space calculated by Fowler’s method corrected to rebreathed CO2. There is a linear relationship between Vt and Vds. Setting PS to achieve low Vt may reduce the level of Vds.

load per se. The objective was to investigate the effect of combined bilateral PE, PEEP and dobutamine on LV preload in piglets. Method: Animals were mechanically ventilated and chest tubes were inserted. Bilateral PE was created using vegetable oil (30 mL/kg) distributed equally on each side. Randomized PEEP levels (5, 10 and 15 cmH2O) and incremental dobutamine doses (3, 5, 10, 15 and 20 lg/kg/min) were administered. Hemodynamic parameters, ultrasonographic measures of preload and blood gases were measured. Preliminary Results: PE caused a ⅓ decline in PaO2 from baseline levels and increased pulmonary vascular resistance (PVR). The decline in PaO2 caused by PE was increased at 5 cmH2O PEEP by approximately ⅔ of baseline levels without compromising hemodynamics and left ventricular end-diastolic area (LVEDA). Dobutamine increased cardiac output in a dose-dependent fashion based on heart rate increases with a concomitant decrease in LVEDA. Conclusion: The decline in PaO2 was partially reverted by low levels of PEEP ventilation with preservation of preload and general hemodynamics. PEEP ventilation probably counterbalanced the negative effect of PE on lung volume and thus reduced PVR by lung recruiting. Increments in dobutamine increased cardiac output solely by alterations in heart rate with no additional increase in preload.

O11-07 Novel capnodynamic method for assessment of effective lung volume

Tomas O¨hman, Thorir Sigmundsson, Caroline H€allsj€o Sander, Magnus Hallb€ack, H akan Bj€orne Karolinska University Hospital Solna, Sweden

Fig. 1. Source: https://www.eventure-online.com/parthen-uploa ds/154/SSAI/img1_265127_ZFjjR2HhkN.jpg.

O11-06 Positive end-expiratory pressure ventilation improves arterial oxygenation during experimental pleural effusion without decreasing left ventricular preload Kristian Borup Wemmelund, Peter Juhl-Olsen, Erik Sloth Aarhus Universityhospital, Skejby, Denmark Introduction: Pleural effusion (PE) is a common entity at the ICU often causing challenges to physicians. Previous studies showed that PE compromises hemodynamics, decreases LV preload and causes hypoxemia as an early event. PEEP ventilation and inotropic support are widely used on indication of low systemic blood pressure and hypoxemia despite their potential of decreasing pre-

Introduction: Effective lung volume (ELV) is the lung volume that participates in gas exchange. It can be calculated continuouslyby a capnodynamic equation and potentially used to optimize ventilator settings in mechanically ventilated patients. A clinical applicable monitor for ELV is lacking. The aim of the current pilot study was to measure ELV in mechanically ventilated patients at different positive end expiratory pressure (PEEP) levels. Methods: A cyclic sequence of breaths with a respiratory hold alternated with normal breaths induced periodic changes in alveolar concentration of carbon dioxide. By integrating these variations into the capnodynamic equation ELV was calculated. ELV was measured in 20 healthy, mechanically ventilated patients, undergoing neck surgery. ELV was measured at PEEP zero, 10 and 5 cmH2O. A reference method measuring functional residual capacity using a partial nitrogen wash in/out technique was used for comparison of delta values. Four-quadrant plot allowed measurement of trending ability. Results: ELV changed significantly in response to changes in PEEP from zero to 10 to 5 cmH2O. The corresponding mean values of ELV were 1664, 2337 and 2151 ml respectively. Four-quadrant plot showed a concordance rate of 95%. Conclusions: In the current study ELV varied significantly with different PEEP levels and trending ability was good. These results are congruent with our study in a porcine model (unpublished data). We are still including patients to allow for comparison between two different ventilatory patterns based on sequences of either inspiratory or expiratory hold alternated with normal breaths.


32 O12-02 Increasing apnoeic oxygenation rate for rapid sequence intubation in an emergency department Jen Heng Pek1, Eunizar Omar2, Hui Min Kang3, Ivan Si Yong Chua4, Devin Kian Jin Tan5, Ai Ling Ong6, Evelyn Wong7 1 Singhealth, Singapore, 2Eunizar Binte Omar, Singapore, 3Kang Hui Min, Singapore, 4Ivan Chua Si Yong, Singapore, 5Devin Tan Kian Jin, Singapore, 6Ong Ai Ling, Singapore, 7Evelyn Wong, Singapore

Fig. 1. Eventline showing ELV (ml) at different PEEP levels (n = 20).Source: https://www.eventure-online.com/parthen-uploa ds/154/SSAI/img1_265128_WWqPkXKkta.jpeg

Free Paper Session 12 – Emergency Medicine II O12-01 Pre-hospital management of paediatric hangings Marius Rehn, Elizabeth Foster, David Lockey London`s Air Ambulance, UK Introduction: Paediatric accidental or suicidal hangings are considered to inflict laryngotracheal injuries that increase the risk for difficult airway management. We describe paediatric hangings managed by London`s Air Ambulance (LAA) to guide future dispatch and clinical management. Methods: LAA is an urban physician-led pre-hospital trauma service serving a daytime population of around 10 million. A retrospective trauma database cohort study was conducted to identify all children less than 16 years with hanging as mechanism of injury. Results: LAA attended 23,130 patients during the 15-year study period (2000–2014); 2415 (10.4%) of which were children. Of these, 32 cases (0.01%) pertained to paediatric hanging (1 case excluded due to missing data). Among the 22 (71%) boys and the 9 (29%) girls, median age was 13 years (IQR 9–14). Home was the hanging location in 27 (87%) of the cases, whereas public places and institutions was the scene in 3 (10%) and 1 (3%) case. Suicide was intent in 23 (74%) of the hangings, whereas accidental hangings were seen in 8 (26%) cases. We found 17 (55%) deaths of which 14 were suicides. The doctor – paramedic team intubated 25 (80%) patients, with a 100% success rate. Conclusions: Suicide is a leading intent among children exposed to hanging and preventive measures should target psychiatric morbidity. The majority of victims were intubated by the doctorparamedic team without failed airway management. However, pre-hospital personnel should stay vigilant, as the potential for difficult airways exist in patients exposed to laryngotracheal trauma.

Background: Apnoeic oxygenation has been proven to provide a safe apnoeic period for intubation without causing desaturation especially during prolonged or difficult intubation in the context of an emergency rapid sequence induction (RSI). It does no harm, and is a cheap and accessible technique. Objectives: We aim to improve the rate of apnoeic oxygenation for RSI carried out within our department of emergency medicine. Methodology: By going through several PDSA cycles, we have identified interventions that helped improve rate of apnoeic oxygenation during RSI and its compliance. The following interventions were done: training and education of doctors and nurses, posters as reminder and a checklist for use during RSI. Results: A survey was carried out among 173 doctors and nurses. Although 139 (80%) of them have heard of apnoeic oxygenation, but only 78 (45%) of them believed that apnoeic oxygenation was of proven benefit. This translated to only 17 (10%) personnel carrying out apnoeic oxygenation 100% of the time in their practice. As such, the rate of apnoeic oxygenation was low at 32.3%. Following our interventions for 3 months, the rate has increased steadily to 85.7%. For this result to be sustained, regular training of new personnel posted to the department was necessary as dips in compliance were noted during personnel changeover periods. Conclusion: Through simple interventions carried out in a sustained manner, personnel could put evidence based medicine into clinical practice to improve outcomes during RSI for our critically ill patients in the emergency department.

O12-03 Time is limb: acute axillary artery embolism mimicking as Stroke Sohil Equbal Pothiawala, Irfan Abdulrahman Sheth, Yih Yng Ng Singapore General Hospital, Singapore Introduction: Human atrial natriuretic peptide (hANP) is a cardiac peptide exhibiting various biological functions including renal protection and diuresis. In our preliminary study, low-dose hANP increased urine volume and maintained hemoglobin (Hb) concentration. In the current study, we investigated the effects of lowdose hANP during prolonged anesthesia more than 8 h. Methods: Twenty patients (ASA-PS:I-II, 40–80 year-old) undergoing oral maxillofacial surgery (duration of anesthesia > 8 h) were enrolled in this study. Patients were divided into two groups: hANP group receiving low-dose hANP (0.01 lg/kg/min). Anesthesia was maintained with 1–3% sevoflurane, fentanyl and remifentanil. The urine volume was maintained at 3–5 ml/kg/h, and stroke volume variation was kept at less than 13%. Hb concentration, PaO2 and serum and urinary electrolytes were evaluated every 2 h. Infusion volume, urine volume, blood loss and hemodynamic condition were also recorded. Results and conclusions: The infusion volume was 6.9 1.5 ml/kg in the control group and 11.9 2.8 ml/kg in the hANP group for the first 8 h from the start of anesthesia (P = 0.0025). The urine volume of the hANP group (6.2 2.7 ml/kg/h) was significantly more than that of the control group (1.9 0.9 ml/kg) (P = 0.0005). In the


33 control group, Hb concentration decreased from 12.6 1.2 to 9.5 1.6 g/dl, while it decreased from 12.3 1.5 to 10.5 1.8 g/ dl in the hANP group (P = 0.0064). Low-dose hANP during prolonged anesthesia increased urine volume, and decreased Hb concentration lower, which may lead to reduce transfusion risk.

O12-04 An unusual case of undifferentiated shock – rapid diagnosis through bedside ultrasound in the emergency department Si Yong Ivan Chua, Faraz Zarisfi Singapore General Hospital, Singapore Introduction: The noninvasive nature of ultrasound, coupled with its portability and ease of use, has made its way into the Emergency Department and has proven to be an excellent diagnostic as well as therapeutic tool. We highlight a case with an unusual presentation that was diagnosed with the use of bedside ultrasound in the ED. Case report: A 48 year old Chinese gentleman presented with sudden onset giddiness and near syncope after passing motion one evening. There was no prior abdominal pain, per rectal bleeding, melena, fever or vomiting. He had hypertension, diabetes, hyperlipidemia and stroke. Also of note was his recent discharge from hospital 1 week ago following open cholecystectomy and drainage of liver abscess for acute empyematous cholecystitis with localized perforation into liver causing a small liver abscess. He completed 4 days of IV Tazocin and 6 days of PO Augmentin. In view of his hypotensive state upon arrival in the Emergency Department, bedside ultrasound was performed in accordance with the RUSH Protocol, as well as examination of the gallbladder fossa. A heterogenous echogenic area was identified in the gallbladder fossa. A CT scan confirmed the diagnosis of a liver abscess. He was started on IV antibiotics and subsequently had drainage of the liver abscess inpatient. Conclusion: Bedside ultrasound is an invaluable tool in patients with undifferentiated shock. We highlight a case where a liver abscess post cholecystectomy was diagnosed on bedside ultrasound in the ED, allowing for prompt treatment and appropriate disposition.

O12-05 Low back pain caused by penetrating atherosclerotic ulcer of the abdominal aorta Sohil Equbal Pothiawala, Mohamed Madeena Faizur Rahman Singapore General Hospital, Singapore Introduction: Low back pain is the most common musculoskeletal complaint that results in a visit to the emergency department. The common diagnoses of low back pain are lumbar strain, lumbosacral radiculopathy, osteoarthritis, degenerative disc disease, spinal stenosis, etc. Case report: A 63-old hypertensive male presented with a 1 day history of low back pain which started after carrying heavy weight. His examination revealed stable vital signs, severe back pain and no neurological deficit. X-ray of lumbosacral spine was normal. His symptoms persisted after analgesia. Bedside ultrasound revealed abdominal aorta measuring 1.54 cm with an intimal flap. CT aortogram showed atheromatous plaque in the posterior aspect of infrarenal abdominal aorta. He underwent endovascular repair of abdominal aortic ulcer. Discussion: PAU is defined as an atherosclerotic lesion with ulceration penetrating the internal elastic lamina and the media of the aortic wall and it representing a different aortopathy from that of classical aortic dissection. Thoracic and abdominal PAU has been considered responsible for 2–7% and 1–5% of all aortic ruptures, respectively. PAU may be complicated by aortic intramural hematoma, subadventitial pseudoaneurysm (SAP) formation in cases of hematoma extension along the media and subsequent stretching of the weakened aortic adventitia, as well as aortic rupture. A high degree of clinical suspicion is crucial for its diagnosis. An aggressive management approach is needed because of their tendency to rupture. Conclusion: This case re-emphasizes the need to consider the uncommon presentations in the differential diagnosis of patients presenting with low back pain.

O12-06 Prehospital CT diagnostics of spontaneous subarachnoidal haemorrhage Maren Ranhoff Hov1, Annette Ryen Olsen2, Thomas Lindner1, Janne Guldteig Storflor2, Jostein Gleditsch2, Christian Georg Lund3 1 The Norwegian Air Ambulance Foundation, Norway, 2Østfold Hospital, Norway, 3Oslo University Hospital, Norway

Fig. 1. US image of liver abscess.Source: https://www.eventureonline.com/parthen-uploads/154/SSAI/img1_264931_zYifkuIFOJ.png

Introduction: Acute cerebral injury due to disruption of cerebral blood flow is one of the most time critical medical incidences. The clinical presentation of cerebral ischemia or haemorrhage is impossible to distinguish clinically and requires in-hospital radiological examination. We present a case report which demonstrates the importance of developing prehospital cerebral diagnostics. Methods: The Norwegian Air Ambulance and the local hospital of Østfold are at present running a clinical pilot study of prehospital diagnostics of acute stroke, by responding to patients with symptoms of acute stroke using a specialized (stroke) ambulance equipped with an anaesthesiologist and a CT scanner. The study is exploiting the possibilities of prehospital cerebral diagnostics and triage in a helicopter emergency medical service (HEMS) model. Results: A previously healthy man presented with acute onset of severe headache. The stroke ambulance arrived at the scene within 30 min from symptom onset. The patient was awake with a severe headache. A cerebral CT scan was performed immediately and the anaesthesiologist interpreted the scan as a subarachnoidal haemorrhage. The scan was send by telemedicin to the local hospital for re-


34 certification. The patient was transferred directly to the regional neurosurgical department saving at least 3–4 h avoiding time consuming diagnostics in the local hospital and extra transportation time. Conclusion: Prehospital diagnostics allowing triage of patients with acute stroke or cerebral trauma may reduce symptom to definite treatment time and enhance the prognosis for the patients.

Free Paper Session 13 – CPR, ECMO, Transplantation O13-01 Recognizing the causes of in-hospital cardiac arrest – a survival benefit Daniel Bergum, Bjørn Olav Haugen, Trond Nordseth, Ole Christian Mjølstad, Eirik Skogvoll St.Olav University Hospital, Norway Introduction: The emergency teams (ET) may or may not recognize the causes of in-hospital cardiac arrest (IHCA). In a previous 4.5-year prospective study, the causes of cardiac arrest (CA) were reliably determined through close retrospective investigation in 258 of 302 episodes (85%). The rate of recognition of CA causes by the ETs was approximately 66% (198 of 302 episodes). In this study we investigated whether survival was increased if causes of IHCA were recognized by the ETs during the provision of advanced life support (ALS). Methods: We analysed survival according to whether or not the causes of IHCA were recognized by the ETs involved. The difference in survival probability if causes of arrest were recognized versus not recognized by the ETs was estimated after propensity score matching these two groups. ALS-related variables commonly known to affect the outcome of IHCA were found to be balanced between the two groups. Results: Overall survival to hospital discharge was 25%. The crude survival benefit if causes were recognized by the ETs was 28% (P < 0.001), mainly found in patients with non-cardiac causes and non-shockable presenting rhythms. Patient records and pre-arrest clinical symptoms were found to be the information sources most frequent utilized by the ETs when they correctly recognized causes of arrest. Conclusions: This cohort of patients suffering an IHCA showed a substantial survival benefit if the causes of arrest were recognizable to the ETs. Patient records and pre-arrest clinical symptoms were the sources of information most frequently utilized in these instances.

O13-02 Quantified EEG reactivity may predict outcome after cardiac arrest. A pilot study Christophe Duez, Hans Kirkegaard, Jørgen Feldbæk Nielsen, Mads Qvist Ebbesen, Birger Johnsen Aarhus Universitet og Universitetshospitalet, Denmark Introduction: EEG reactivity (EEG-R) to noxious stimulation is an important prognostic parameter in comatose patients. Assessment of reactivity, however, relies on a visual qualitative evaluation prone to subjective interpretations. The aim of this study was to test if quantified analysis of EEG has a potential as an objective method for the evaluation of EEG-R. Methods: We conducted EEG in 17 lightly sedated out-of-hospital cardiac arrest (CA) patients during the first 12–24 h of therapeutic hypothermia. We used three periods of 30 s with and three periods without noxious stimulation, and calculated stimulation/rest ratios from the power in the alpha, theta and delta bands. We then calculated the alpha/theta-, alpha/delta-, and theta/delta ratios. Out-

come was assessed by the Cerebral Performance Category Score (CPC) 3 months after CA. Results: Alpha/delta reactivity ratio (ADRR), defined as the ratio of the alpha/delta ratio during noxious stimulation to the alpha/delta ratio without stimulation, was the best predicting parameter with an area under the ROC-curve of 0.96 (CI: 0.87–1.00), a specificity of 84, 24% and a sensitivity of 100% for the optimal cut-off at an ADRR of 1.14. Six patients had an ADRR above 1.14 and 4 of these had a poor outcome (CPC 3–5). All 11 patients with an ADRR below 1.14 had a good outcome (CPC 1–2). Conclusions: This pilot study suggests that quantification of EEGR may predict good outcome in sedated CA patients within the first 24-h of therapeutic hypothermia.

Fig. 1. Y-axis = Alfa/Delta ratio, X-axis = patients. Blue patients had a good outcome (CPC 1–2). Red patients had a bad outcome (CPC 3–5). Source: https://www.eventure-online.com/parthen-upl oads/154/SSAI/img1_265121_Z4KXoIWVg2.jpg

O13-03 Quantification of the life-saving potential in public access defibrillation Marianne Agerskov1, Anne Møller Nielsen2, Marco Bo Hansen2, Carolina Malta Hansen3, Fredrik Folke4, Mads Wissenberg3, Freddy Knudsen Lippert4, Lars Simon Rasmussen2 1 Centre og Head and Orthopaedics, University of Copenhagen, Denmark, 2 Centre of Head and Orthopeadics, University of Copenhagen, Rigshospitalet, Denmark, 3Gentofte Hospital, University of Copenhagen, Denmark, 4Emergency Medical Services Copenhagen, University of Copenhagen, Denmark Introduction: In Copenhagen, a volunteer-based Automated External Defibrillator (AED) network provides a unique opportunity to assess AEDs use. We aimed to determine the proportion of Out-ofHospital Cardiac Arrest (OHCA) cases where an AED was applied before arrival of the Emergency Medical Services, and the proportion of OHCA-cases where an accessible AED was located within 100 metres. In addition, we assessed 30-day survival. Methods: Using data from the Mobile Emergency Care Unit and the Danish Cardiac Arrest Registry, we identified 521 OHCA-cases


35 between October 1, 2011 and September 31, 2013 in Copenhagen, Denmark. Results: The exact location of 436 OHCA-cases could be identified and an AED was applied in 20 cases (3.8%, 95% CI [2.4–5.9]). In 102 (23.4%, 95% CI [19.5–27.7]) cases, an AED was located within 100 metres, but at the time of OHCA, only 66 (15.1%, 95% CI [11.9–18.9]) cases were located within 100 metres of an accessible AED, and in seven of those (10.6%, 95% CI [4.9–20.6]) an AED was applied. The 30-day survival of all-rhythm-OHCA was 50% for patients where an AED was applied and 19% for patients where an AED was not applied, P = 0.0023, OR 4.3 (95% CI [1.7–10.5]). Conclusions: An AED was applied in a minor proportion of all OHCA-cases, but only 10.6% of OHCAs occurring within 100 metres of an accessible AED had an AED applied. The significantly higher survival associated with AED use indicates the life-saving potential of utilizing public access defibrillation.

O13-04 Preliminary analysis of cardiac arrest patients who underwent therapeutic hypothermia postresuscitation

O13-05 Extracorporeal life support (ECLS) for out-ofhospital cardiac arrest in a Scandinavian setting Aage Christiansen, Jakob Gjedsted, Jacob Raben Greisen, Jens Flensted Lassen, Peter Fast Nielsen, Lars Ilkjær, Steffen Christensen, Evald Høj Christiansen Aarhus University Hospital, Denmark Introduction: Scandinavian pre-hospital organisations vary great due to the different geographical challenges. The Danish geography favours rapid transport to hospital services. Extra-corporeal life support (ECLS) has shown encouraging results in refractory out-of-hospital cardiac arrest (OHCA) regarding survival and neurological outcome. Methods: Retrospective evaluation of 13 patients (8 male) treated with ECLS from 2011 to 2013. All patients had witnessed refractory OHCA and received ACLS by an anaesthesiologist-staffed pre-hospital mobile emergency service (EMS), including advanced airway management and continuous mechanical chest compressions during transport to a cardiac catheterization laboratory at an extracorporeal membrane oxygenation (ECMO) centre. An algorithm aided selection to ECLS (Fig.).

Sohil Equbal Pothiawala1, Mingwei Ng2, Aaron Sung Lung Wong3, Huck Chin Chew1, Shahidah Nur1, Pin Pin Pek1, Juliana Poh1, Chee Tang Chin3, Terrance Siang Jin Chua3, Marcus Eng Hock Ong1 1 Singapore General Hospital, Singapore, 2Yong Loo Lin School of Medicine, National University Health System, Singapore, 3National Heart Center, Singapore Introduction: Therapeutic Hypothermia (TH) is standard of care in patients with return of spontaneous circulation after out-of-hospital cardiac arrest (OHCA). Objective is to identify demographics of post-resuscitation patients who underwent TH in tertiary hospital in Singapore and to evaluate neurological function using GlasgowPittsburg Score upon discharge. Methods: Retrospective analysis of OHCA patients who had ROSC and commenced on TH was conducted from October 2008– September 2014. Data was obtained from ED and inpatient records. Demographics of patients were gathered including method of TH and overall survival to hospital discharge. Results: Total of 51 consecutive patients were analyzed and 6 were excluded due to incomplete treatment. 23 (51.1%) patients underwent internal cooling and 22 (48.9%) patients underwent external cooling. Among internal cooling group, 16 (69.5%) were males and mean age was 59.5 years (SD 14.3); among external cooling group, 19 (86.3%) were males and mean age was 59.1 years (SD 13.5). Overall survival to hospital discharge or survival at 30 days was 42.2% (19 patients), which was higher compared to our historical survival of 16%. Survival to discharge trended higher in patients with internal cooling as compared to external cooling although not statistically significant [11 (47.8%) vs 8 (36.4%), P = 0.32]. 13 (68.4%) of survivors had good neurological outcome (CPC 1 & 2). Survivors in internal cooling group had good neurological outcome [CPC 1/2: 8/11 (72.7%) as compared to those in external cooling group 5/8 (62.5%)]. Conclusion: This study suggests that implementation of TH improved neurologically intact survival to hospital discharge.

Fig. 1 Source: https://www.eventure-online.com/parthen-uploads/154/SSAI/ img1_265120_IZHuhxSOvU.jpeg

Results: Five patients (38.5%) survived with a Cerebral Performance Category score (CPC) of 1–2. Survivors was 61 years (9) of age and non-survivors was 38 (15). All patients received immediate bystander CPR. Initial rhythm was ventricular fibrillation in 7 (53%) patients, pulseless rhythm in 5 patients (38,5%) and asystole in 1 patient (7.7%). Four (80%) survivors had ventricular fibrillation as initial rhythm. Low-flow time was 153 (36) among survivors versus 121 (29) among non-survivors. Causes of death were cerebral incarceration, severe brain damage, cardiopulmonary failure, bleeding, and severe lower limb ischemia/necrosis. Conclusions: Our data suggests that with a anaesthesiologiststaffed EMS including advanced airway management and mechanical chest compressions combined with a pre-defined ECLS algorithm, acceptable outcome for refractory OHCA can be achieved in spite of prolonged low-flow times; however, many questions regarding indications and strategies to reduce pre-hospital and inhospital low-flow time still exist.


36 O13-06 Infectious complications in Extracorporeal Membrane Oxygenation (ECMO) patients Danielle E. Austin1, Priya Nair1, Stephen Kerr2, Suhel Al-Soufi1 1 St Vincent’s Hospital, Australia, 2University of New South Wales, Australia Introduction: Alongside haemostatic complications, infectious complications remain a signficant contributor to morbidity and mortality in ECMO patients, despite better outcomes overall. Characterising infections and associated risk factors will aid to inform patient care and antimicrobial therapy decisions. Methods: Ninety-nine adult patients receiving ECMO therapy for > 48 h in a single ECMO and cardiopulmonary transplant centre were studied over a 3-year period. Demographic, ECMO-related and clinical data related to potential infection risk factors were collected. Infections studied included blood stream infections (BSI), wound infections (WI) and sternal wound infections (SWI) and were defined using CDC crtieria. Comparisons of covariates between patients that did and did not develop infections were made using univariate analysis. Multivariate logistic regression was used to calculate odds ratios (OR) for the risk of developing any infection. Results: The median (IQR) age was 50 (39–57) years, 62% were male, 41% received immunosuppression, 56% were on renal replacement therapy, and 61% received insulin infusions. Sixty-six % received VA-ECMO, the majority (83%) were cannulated peripherally and remained on ECMO for a median of 6 (4–13) days. Twenty-one patients developed 24 BSI, 14 developed WI at cannulation sites and 2 centrally cannulated patients developed SWI. Factors that increased infection risk on univariate analysis included immunosuppression OR 2.9 (P = 0.04), VA-ECMO-OR 14.7 (P = 0.01), cardiac transplant OR 6.2 (P = 0.001). Of these, immunosuppression and VA-ECMO remained significant on multivariate analysis. Conclusions: Infections are common in ECMO patients and are associated with the presence of immunosuppression and VAECMO but not with age, BMI, ECMO duration, hyperglycaemia or organ dysfunction.

O13-07 Point-of-care monitoring of coagulation during mechanical circulatory support Antti Laine1, Tomi Niemi2, Raili Suojaranta-Ylinen2, Peter Raivio2, Leena Soininen2, Karl B. Lemstr€om2, Alexey Schramko2 1 Helsinki University, Helsinki University Hospital, Finland, 2Helsinki University Hospital, Finland Introduction: We aimed to characterize coagulation disturbances which may increase the risk of bleeding, thrombosis or death shortly after implantation of extracorporeal membrane oxygenation (ECMO) or ventricular assist (VAD) device. Methods: Antithrombotic treatment was started in 23 VAD and 24 ECMO patients according to the hospital protocol. Additionally to conventional laboratory testing, rotational thromboelastometry (ROTEMâ) and platelet function analyses (PFA-100â, Multiplateâ) were performed at predetermined intervals. Results: 4/24 of ECMO and 6/23 of VAD patients had severe bleeding after procedure. Low maximum clot firmness (MCF) in ExTEM and FibTEM analyses correlated with severe bleeding (P < 0.05) and low MCF in FibTEM with 30-day mortality, which was not observed with conventional coagulation tests.

Four patients with VAD had cerebral ischemia indicative of embolism. However, this had no significant correlation with ROTEMâ or Multiplateâ parameters. Conclusion: Hypocoagulation, shown by ROTEMâ is associated with bleeding complications in patients with extracorporeal circulation assist device. In contrast, hypercoagulation did not correlate with clinical thrombosis.

O13-08 Surface versus endovascular therapeutic hypothermia evaluated by cerebral diffusionweighted MRI in a randomized porcine model Anders Grejs, J. Gjedsted, M. Pedersen, K.K. Andersen, H. Kirkegaard Aarhus University Hospital, Denmark Introduction: Therapeutic hypothermia (TH) reduces morbidity and mortality after out-of-hospital cardiac arrest and is a recommended therapy. Our understanding of all the exact mechanisms is lacking. Apparent Diffusion Coefficient (ADC) is derived from diffusionweighted MRI of the brain. It is a powerful clinical relevant tool for studying brain ischemia by detecting intracellular water migration. Cytotoxic oedema, hypothermia itself and changed metabolism all result in lowering ADC. The objective of this study was to compare the effect of surface versus endovascular cooling methods on both ADC and stress biomarkers. Methods: Eighteen anaesthetized 60 kg female pigs were subjected to cerebral MRI using a 1.5 Tesla scanner and subsequently randomized in 3 groups: 1) Surface cooling (33.5°C) using EMCOOLSâ pads, 2) Endovascular cooling (33.5°C) using Alsius Coolgard 3000â, or 3) Control (38.5°C, porcine normothermia). The pigs were treated with TH for 6 h, followed by a second MRI, where cerebral ADC was measured. Arterial and venous blood was sampled hourly throughout the experiment. Results: Surface cooling yielded a significant lower ADC than both endovascular cooling (727 112 vs. 882 93 9 106mm2/s, P-value < 0.022) and the control group (727 112 vs. 935 68 9 106 mm2/s, p-value < 0.003). Levels of p-epinephrine and p-norepinephrine did not differ in any of the groups.

Fig. 1. Showing the significant difference in the cerebral MRI: Apparent Diffusion Coefficient in the surface cooling group. Source: https://www.eventure-online.com/parthen-uploads/154/ SSAI/img1_265057_eN2eEBxvQl.jpg


37 Conclusion: Both cooling methods resulted in lower ADC but surface cooling showed significant lower ADC. As our study have no ischemic intervention and the impact of hypothermia per se was evaluated, the result could be explained by reduced cerebral metabolism. The clinical implications have to be tested in human studies.

O13-09 Unexpected gender bias among organ donors in Sweden during 2009–2013. A nationwide observational study Sten Walther1, Thomas Nolin2 1 Heart Centre, Sweden, 2Central Hospital, Sweden Introduction: The gap between the number of organ donors and patients on waiting lists for transplantation is wide globally. Understanding reasons for variation in organ donation between and within countries may lead to increased availability of organs for transplantation. The purpose of the present analysis was to examine age and gender of organ donors in Sweden. Methods: All deaths in Swedish ICUs during 2009–2013 were examined using a prospectively determined protocol comprising 10 primary questions. Protocols were sent electronically to the Swedish Intensive Care Registry (SIR) for validation and then joined with the appropriate ICU admission in the SIR database. The relationship between organ donation and gender was analysed using logistic regression adjusted for age and comorbidities (as defined in the SAPS3 model) and presented as odds ratios (OR). Results: The female to male ratio (F/M) was 0.72 in ICU admissions and ICU deaths, while the organ donor F/M was 1.06. Almost all organ donors (98%) were found in 4 major diagnostic groups which all showed a disproportionate high female donor rate (Table). Mean age in female organ donors was 54.9 (SD 16.5) years. and in men 53.5 (18.3) years, P = 0.48. The crude female OR for becoming a donor was 1.47 (95% CI: 1.25–1.74, P < 0.001), and the adjusted OR was 1.55 (95% CI: 1.28–1.88, P < 0.001).

patients that die in the ICUs. To fulfill the patients wish for organ donation and meet the increased demand for organ transplantation we have established a program for cDCD with the use of RNP for in situ organ preservation. The protocol was approved by the Regional Ethical Committee, Norwegian Directorate of Health and finally the Ministry of Health and Care Services which stated that the cDCD protocol was in accordance with Norwegian Law. The study was presented at Centre for Medical Ethics, acknowledged by local ethical committee and given permission to start by board meeting at Division of Emergencies and Critical Care, Ullev al University Hospital. Objectives:

To describe the steps taken to establish the protocol. To present two patient cases.

A

B

Table 1 Source: https://www.eventure-online.com/parthen-uploads/154/SSAI/ img1_264985_Nxx2LShLTc.jpg.

Conclusion: During the critical pathway for organ donation after brain death the F/M ratio unexpectedly rose. Why and when men became underrepresented in this pathway needs further study.

C

O13-10 Controlled Organ Donation after Circulatory Death (cDCD) with use of regional normo termic perfusion (RNP): case report of two patients in Norway Dag Wendelbo Sørensen1, Stein Foss2, Torgunn Syversen1, Morten Hageness2, Aksel Foss2, Fiane Arnt2, Odd Geiran2 1 Oslo University Hospital, Ullev al, Norway, 2Oslo University Hospital, Rikshospitalet, Norway Introduction: The numbers of patients which progress to a total loss of brain perfusion make up a relatively small fraction of all

Fig. 1 FOG weakened contraction by PE in aorta from wild type (A) but not P2X7R knock-out (B) mice. Human artery secreted cytokines by FOG (C). Source: https://www.eventure-online.com/parthen-uploads/154/SSAI/ img1_265091_2uDkM6YCKo.jpg


38 Results: Two males, one with penetrating brain injury, the other with intracranial hemorrhage, fulfilled the cDCD criteria. Next of kin supported organ donation and in agreement with the medical staff, life-sustaining treatment was withdrawn. Permanent cardiac arrest occurred after 13 and 10 min, respectively. RNP was applied for 54 and 106 min prior to kidney retrieval. Four kidney recipients were successfully transplanted and discharged with normalized creatinine levels. Conclusion: The implementation of cDCD has proven to be a challenge for the medical, ethical and transplant community. However, excellent transplant results and satisfied next of kin and ICU staff have encouraged us to continue the use of cDCD.

Free Paper Session 14 – Infection/Coagulation O14-01 Purine receptor P2X7 mediates an inflammatory response to group G streptococcal protein FOG in blood vessels and monocytes Mikael Bodelsson, Johan T€ornebrant, Inga-Maria Frick, Matthias M€ orgelin Lund University, Sweden

Introduction: Activation of innate immunity by bacterial factors results in inflammation potentially leading to septic shock. The increasingly prevalent group G streptococci express fibrinogenbinding protein (FOG), which inhibits neutrophil function and activates monocytes. We hypothesized that FOG can trigger an inflammatory response leading to vascular dysfunction. Methods: Segments of rat and mouse aorta and isolated human omental arteries and monocytes were incubated in the presence or absence of FOG or endotoxin. Effects of inhibitors of receptors and intracellular signaling pathways on smooth muscle contraction and release of nitric oxide and cytokines were investigated. Results: Rat and mouse aorta incubated with FOG constricted weaker in response to phenylephrine and released more nitric oxide and interleukin-1b than control, similar to endotoxin. FOGinduced NO accumulation was independent of MyD88/Toll-like receptors but was mimicked by the purine receptor P2X agonist, BzATP. The effects by FOG were inhibited by the P2X7 receptor (P2X7R) antagonist, KN-62. In electron micrographs, immunogold labeled FOG co-localized with P2X7R on plasma membrane of human and wild type mouse vascular smooth muscle cells. FOG neither bound to, nor elicited pro-inflammatory effects in aorta from P2X7R knockout mice. FOG induced a P2X7R-dependent release of TNF-a and interleukin-1b from isolated human blood vessels and monocytes. Conclusions: FOG causes contractile hyporeactivity and an inflammatory response in blood vessels and monocytes, an effect that could contribute to septic shock induced by group G streptococci. P2X7R, a purine receptor, mediates the response and thus provides a potential therapeutic target in streptococcal septic shock.

O14-02 Iatrogenic epidural empyema after peripheral venopuncture

Pedro Manuel Simoes Freire1, Daniel Alexandre Olas Ferreira2, Antonio Jos e Pais Martins1 1 Centro Hospitalar Lisboa Ocidental, Portugal, 2Hospital Espirito Santo, Portugal Introduction: Epidural empyema is rare accounting for only 1 : 10,000 within the causes of hospital admissions. Associated

with a high rate of morbidity and mortality, its difficult diagnose almost always delays institution of adequate therapy. Methods: Clinical file consultation.Informed consent was obtained from relatives for publication of case. Results: We hereby describe the case of a 62 year old man, with known history of ankylosing spondylitis under long term systemic corticosteroid therapy, admitted in an orthopedic ward for a D5 fracture with two months of evolutionbut without neurologic deficits.One week after admission the patient was transferred to the ICU in septic shock with pulmonary cause. In the ICUthe patient remained unstable despite vasopressor support even entering in cardiac arrest reverted within thefirst cycle of advanced life support. Multiple antibiotic schemes were prescribed according to the microbiologicresults with improvement of clinical status.Weaning was initiated but flaccid tetraparesia was noted. Differentialdiagnosis included Critical Illness Neuropathy but electromyography was unavailable in our institution.MRI was then performed, revealing an extensive cervical and dorsal epidural empyema. Sample of the abscesswas surgically collected with isolation of Staphilococcus epidermidis and despite multiple antibiotic schemesclinical status of patient continued worsening and he died after 3 months in the ICU. Conclusions: Differential diagnosis of tetraparesia in ICU environment is difficult and may sometimes include rare and almostunthinkable causes. Perhaps it’s time to think how aseptic precautions should peripheral venous puncture of immunosuppressed patients be.

O14-03 Complement inhibition may be lifesaving in the ICU Andreas Barratt-Due, Hilde Lang Orrem, Geir E. Tjønnfjord, Tom Eirik Mollnes Oslo University Hospital, Rikshospitalet, Norway Introduction: We present a 35-year-old female with a known history of antiphospholipid syndrome, now admitted with staphylococcus aureus wound infection and sepsis. Biochemistry revealed anemia, thrombocytopenia, low haptoglobin and high levels of antiphospholipid antibodies. During the following week her condition deteriorated dramatically with increased respiratory distress, circulatory collapse and cardiac arrest. She was resuscitated, intubated, required vasoactive medication and developed acute kidney failure. The critical situation was perceived as fulminant catastrophic antiphospholipid syndrome (CAPS), a condition known to induce multiple organ thrombosis wherein the pathogenesis is thought to be strongly complement dependent. Thus, treatment with eculizumab, a monoclonal antibody against the complement component C5, was given. Results: The patient improved remarkably, both clinically and biochemically. Within 6 h, heart rate and the need for vasoactive treatment decreased, and after three days she did not require respiratory support and the kidney failure ceased. The soluble terminal complement complex (TCC/sC5b-9) was extremely elevated (1391 ng/ml) prior to the administration of eculizumab, but decreased abruptly thereafter, reaching 239 ng/ml after 24 h and as low as 47 ng/ml after the third dose. Additionally, biochemical results demonstrated an abrupt decrease in lactate dehydrogenase and similar effect on inflammatory markers as procalcitonin and ferritin within days after administration of eculizumab. Conclusion: The current patient demonstrated exceptionally high complement activation associated with clinically fulminant CAPS, and it is plausible to suggest that treatment with eculizumab was


39 alloids expand plasma by 8.7% (95% CI 3.5–14, R2 0.24) of the infused dose. At 60 min after resuscitation PV had decreased to pre-resuscitation levels in all resuscitation groups and were similar to non-resuscitated animals. Mean arterial pressure and urine production did not differ between the groups. Conclusion: The dose response relationship between crystalloids and plasma volume expansion is linear to a dose of 50 ml/kg. Crystalloids are poor plasma volume expanders in severe sepsis and do not restore normovolemia in the current doses.

Fig. 1. Plasma volume expansion (DPV) at 15 min after resuscitation with a balanced crystalloid solution (Plasmalyteâ) in septic rats. Source: https://www.eventure-online.com/parthen-uploads/154/ SSAI/img1_265038_fY4KhtCDzZ.jpg Fig. 1 Source: https://www.eventure-online.com/parthen-uploads/154/SSAI/ img1_265030_Up1tiMOool.jpg

lifesaving. Intensivists must be aware of complement inhibition as a therapeutic option, as different life-threatening conditions strongly benefit on such target specific treatment.

O14-04 Is plasma volume expansion a linear function of the administered dose of crystalloid in a rat model of severe sepsis? Svajunas Statkevicius, Peter Bentzer Lund University, Sweden Background: Clinical sepsis studies suggest that crystalloids are almost equally efficacious as colloids when resuscitation is guided by clinical endpoints whereas recent experimental studies indicate that crystalloids in a high dose expand plasma volume by only about 5–10% of the administered volume. We hypothesized that these contradictory results could be explained by an un linear dose response relationship between crystalloids and plasma volume. Methods: Severe sepsis (decrease in plasma volume (PV) > 5 ml/ kg, hypotension and lactate > 3.5 mmol/l) was induced using the cecal ligation and incision (CLI) model in anesthetised rats. Animals were randomized to resuscitation with a balanced crystalloid solution (Plasmalyteâ) at a dose of 10 ml/kg (n = 9), 30 ml/kg (n = 10) or 50 ml/kg (n = 10), or no resuscitation (n = 9). PV was measured using radiolabeled albumin prior to CLI and at 15 min and 60 min after resuscitation. Results: PV was 44.0 3.6 ml/kg at baseline and decreased by 26.7 5.7% following induction of sepsis. PV at 15 min after resuscitation was a linear function of administered dose and cryst-

O14-05 Low-dose human atrial natriuretic peptide (hANP) may reduce the risk of blood transfusion during anesthesia Masanori Tsukamoto Kyushu University, Japan Introduction: Human atrial natriuretic peptide (hANP) is a cardiac peptide exhibiting various biological functions including renal protection and diuresis. In our preliminary study, low-dose hANP increased urine volume and maintained hemoglobin (Hb) concentration. In the current study, we investigated the effects of lowdose hANP during prolonged anesthesia more than 8 h. Methods: Twenty patients (ASA-PS:I-II, 40–80 year-old) undergoing oral maxillofacial surgery (duration of anesthesia > 8 h) were enrolled in this study. Patients were divided into two groups: hANP group receiving low-dose hANP (0.01 lg/kg/min). Anesthesia was maintained with 1–3% sevoflurane, fentanyl and remifentanil. The urine volume was maintained at 3–5 ml/kg/h, and stroke volume variation was kept at less than 13%.Hb concentration, PaO2 and serum and urinary electrolytes were evaluated every 2 h. Infusion volume, urine volume, blood loss and hemodynamic condition were also recorded. Results and Conclusions: The infusion volume was 6.9 1.5 ml/kg in the control group and 11.9 2.8 ml/kg in the hANP group for the first 8 h from the start of anesthesia (P = 0.0025). The urine volume of the hANP group (6.2 2.7 ml/kg/h) was significantly more than that of the control group (1.9 0.9 ml/kg) (P = 0.0005). In the control group, Hb concentration decreased from 12.6 1.2 to 9.5 1.6 g/dl, while it decreased from 12.3 1.5 to 10.5 1.8 g/dl in the hANP group (P = 0.0064). Low-dose hANP during prolonged anesthesia increased urine volume, and decreased Hb concentration lower, which may lead to reduce transfusion risk.


40 O14-06 Prediction of survival in patients suspected of DIC using antithrombin, protein C, alpha-2antiplasmin, and ISTH score Einar Hjo¨rleifsson1, Gisli Heimir Sigurdsson1,2, Martin Ingi Sigurdsson2, 1,2 € Brynja R Gudmundsdottir3, Pall Torfi Onundarson 1 University of Iceland, School of Health Sciences, Iceland, 2Brigham and Women0 s Hospital, United States of America, 3Landspitali National University Hospital, Iceland Introduction: The purpose of this study was examine the association of antithrombin, protein C and alpha-2-antiplasmin with mortality in critically ill patients, both fulfilling and not fulfilling criteria for overt disseminated intravascular coagulation (DIC) set forth by the International Society of Thrombosis and Haemostasis (ISTH). Methods: All consecutive patients suspected of acute DIC over a 5 year period at a single tertiary care hospital were identified and scored according to overt ISTH criteria. The influence of ISTH score, antithrombin, protein C and antiplasmin measurements on mortality was assessed. Results: There were 1825 occurrences in 1814 patients, 92 with ISTH score ≥ 5. The 28-day mortality was 3, 11, 16, 23, 35 and 52% and the one year mortality was 5, 18, 24, 36, 54 and 63%, respectively for patients with an ISTH score of 0, 1, 2, 3, 4 and ≥ 5 (P < 0.001). Antithrombin and protein C correlated inversely with both the ISTH score (P < 0.001) and APACHE II score (P < 0.001). Antiplasmin decreased when the ISTH score was above 3. Both the 28 day and one-year mortality increased progressively as antithrombin and, in particular, protein C decreased. One-year survival was higher in those with the lowest antiplasmin. Conclusions: The study shows that mortality in patients suspected of acute DIC increases progressively across the spectrum of the overt ISTH score and not only in those fulfilling the ISTH overt DIC criteria. Furthermore, the measurement of protein C appears useful to assess mortality risk upfront in critically ill patients suspected of DIC.

O14-07 Effect of albumin and mannitol combination on thromboelastometry in vitro

€ Kirsim€agi2, Kadri Lillem€ ae1, Antti Laine1, Alexey Schramko1, Ulle 1 Tomi Tapio Niemi 1 University of Helsinki and Helsinki University Hospital, Finland, 2 Tartu University Hospital, Estonia

Introduction: Both albumin and mannitol may interfere with haemostasis but their co-influence on blood coagulation is partly unclear. We aimed to determine the co-effects of albumin and mannitol or Ringer acetate at various haemodilution levels on blood coagulation in randomized cross-over in vitro study. Methods: From citrated fresh whole blood, withdrawn from 10 volunteers, we prepared 2,5, 5, 10, 15 and 20 vol% dilutions of 4% albumin (Alb groups). Each sample was thereafter diluted by 15% mannitol (Alb/Man group) or Ringer acetate (Alb/RAC group) at a ratio of 9 : 1 (an additional 10 vol% dilution). Samples were analysed with thromboelastometry (ROTEMâ) using two activators, FibTEMâ or ExTEMâ. Results: In FibTEM analysis, maximum clot firmness (MCF) decreased more in Alb10/Man and Alb15/Man group than in corresponding dilution in Alb/RAC and Alb groups (P < 0.05). Using ExTEM, clot formation time (CFT) was delayed more in Alb5/ Man, Alb10/Man and Alb15/Man group than in corresponding dilution in Alb/RAC groups (P < 0.05). In Alb2,5/Man and Alb20/Man, CFT was delayed compared to Alb2,5 and Alb20

groups (P < 0.05), but it was not different to the delay seen in corresponding dilutions in Alb/RAC groups. Compared to Alb groups, MCF was weaker in all dilution levels after adding Mannitol or RAC (P < 0.05). In Alb groups, CFT was prolonged in 20 and MCF decreased in 10, 15 and 20 vol% dilution (P < 0.05). Conclusions: Albumin in combination with mannitol impairs haemostasis in vitro. Although it is partly caused by dilutional effects, the simultaneous administration of mannitol and albumin might aggravate bleeding. Table 1 Source: https://www.eventure-online.com/parthen-uploads/154/SSAI/ img1_262967_XB8m3GMzxz.jpg.

O14-08 Thromboelastometric (ROTEMⓇ) analyses show compromised hemostasis when performed at 33°C Anni Noergaard Jeppesen, Hans Kirkegaard, Susanne Ilkjær, Anne-Mette Hvas Aarhus University Hospital, Denmark Introduction: A compromised coagulation may be visualized using a dynamic whole blood coagulation analyses like thromboelastometry, however the temperature of the analyses is ambiguous. The aim was to examine whether thromboelastometry differed when analyzed at 33°C and 37°C in hypothermic and normothermic patients. Methods: We included 40 patients treated with hypothermia (33 1°C) after cardiac arrest. The first blood sample was obtained at hypothermia and the second at normothermia. Each blood sample was analyzed simultaneously at 33°C and 37°C by thromboelastometry (ROTEMâ) using standard assays (EXTEMâ, INTEMâ, FIBTEMâ,and HEPTEMâ). Data regarding antitrombotic drugs were collected using medical records. Results: Comparing the ROTEMâ analyses an increased clotting time, a lower maximum velocity, and an increased time to maximum velocity (all P-values < 0.008) was found at 33°C compared to 37°C independent of the patients being hypothermic (median 33.1°C, range 32.6–34.4°C) or normothermic (median 37.5°C, range 35.8–38.3°C). However, time to maximum velocity in EXTEMâ deviated showing no difference when analyzed at 33°C and 37°C in hypothermic patients (P = 0.63).


41 Conversely, no differences were found in maximum clot firmness (all P-values > 0.08) comparing analyses at 33°C and 37°C in normothermic and hypothermic patients, except for a lower maximum clot firmness in EXTEMâ during hypothermia (P = 0.03). Conclusions: ROTEMâ showed a slower initiation of coagulation when analyzed at 33°C compared to 37°C, but a preserved maximum clot firmness. The results were independent of patients being hypothermic or normothermic.

Free Paper Session 15 – Intensive Care O15-01 Scandinavian clinical practice guideline on mechanical ventilation in adults with the acute respiratory distress syndrome Jon Henrik Laake1, Jonas Claesson2, Morten Freundlich3, Ivar Gunnarsson4, Tero Varpula5, Per Olav Vandvik6, Tor Aksel Aasmundstad1 1 Rikshospitalet – Oslo University Hospital, Norway, 2Department of Intensive Care, Ume a University Hospital, Sweden, 3Aalborg University Hospital, Denmark, 4Landspitali University Hospital, Iceland, 5Helsinki University Hospital, Finland, 6University of Oslo, Norway The objective of the Scandinavian society of anaesthesiology and intensive care medicine (SSAI) task force on mechanical ventilation in adults with the acute respiratory distress syndrome (ARDS) was to formulate treatment recommendations based on available evidence from systematic reviews and randomised trials. Methods: The guideline was developed according to standards for trustworthy guidelines through a systematic review of the literature and the use of the GRADE system for assessment of the quality of evidence and for moving from evidence to recommendations in a systematic and transparent process. Results: We found evidence of moderately high quality to support a strong recommendation for pressure limitation and small tidal volumes in patients with ARDS. Also, we suggest PEEP > 5 cm H2O in moderate to severe ARDS and prone ventilation 16/24 h for the first week in moderate to severe ARDS (weak recommendation, low quality evidence). Volume controlled ventilation or pressure control may be equally beneficial or harmful and partial modes of ventilatory support may be used if clinically feasible (weak recommendation, very low quality evidence). We suggest utilising recruitment manoeuvres as a rescue measure in catastrophic hypoxaemia only (weak recommendation, low quality evidence). Based on high quality evidence we strongly recommend not to use high frequency oscillatory ventilation (HFOV). We could find no relevant data from randomised trials to guide decisions on choice of FiO2 or utilisation of noninvasive ventilation. Conclusion: We recommend pressure- and volume limitation and suggest using higher PEEP and prone ventilation in patients with severe respiratory failure.

O15-02 Long-term survival and Quality of life after intensive care for patients 80 years of age or older

F. H. Andersen1, H Flaatten2, P Klepstad3, U. K. Romild4, R Kv ale2 1 2 Alesund Hospital, Norway, Haukeland University Hospital, Norway, 3 St.Olav0 s Hospital, Norway, 4Nord-Trøndelag Health Trust, Norway

Methods: We retrospectively analyzed survival of ICU patients ≥ 80 years admitted to Haukeland University Hospital in 2000– 2012. We prospectively used the EuroQol-5D to compare health related quality of life (HRQOL) between survivors at follow-up and an age- and gender-matched general population. Follow-up was 1 to 13.8 years. Results: The included 395 patients (mean age 83.8 years, 61.0% males) showed overall survival of 75.9%, 59.5%, and 42.0% during the ICU-stay, hospital-stay, and one year after the ICU, respectively. High ICU mortality was predicted by age, mechanical ventilator support, SAPS II, maximum SOFA, and multitrauma with head injury. High hospital mortality was predicted by an unplanned surgical admission. One-year mortality was predicted by respiratory failure and isolated head injury. We found no differences in HRQOL between survivors at follow-up (n = 58) and control subjects (n = 179), or between admission categories. Life-sustaining treatment limitations were applied for 71.1% (n = 64) of the ICU non-survivors. Conclusions: Overall 1-year survival was 42.0%. Longer survival rates were comparable to those of the general octogenarian population. Among our patients, HRQOL was comparable to that of the age- and sex-matched general population over a follow-up of 1 to 13.8 years. Patients admitted for planned surgery had better shortand long-term survival rates than those admitted for medical reasons or unplanned surgeries for three years after ICU admittance.

O15-03 Recovering patients in Intensive Care Units continue to experience sleep deprivation Dhaneesha N.S. Senaratne1, Duncan Young2, Julie Darbyshire2 1 Oxford University Hospitals NHS Trust, United Kingdom, 2Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom Introduction: Sleep in patients in Intensive Care Units (ICU) is poor. We aimed to assess sleep in non-sedated non-ventilated adult patients in an ICU. Methods: An observational study was performed in a tertiary hospital ICU. Patients aged ≥ 16 years with GCS 15/15 were invited to wear a portable EEG machine for up to 48 h. Sleep stage was determined using the validated auto-staging algorithm. Total sleep time, percentage spent in sleep stages, and duration of unbroken sleep periods were measured. Times are reported as hh : mm. Results: Twelve patients were enrolled (66.7% male), with mean age 61.4. Median APACHE II score was 24.5. Median ICU length of stay was 5.0 days. Median recording duration per patient was 16:47 (range 03 : 29–42 : 02), during which time each patient was asleep for a median of 03:10 (range 00 : 01–12 : 12). Of this time, 3.7% was spent in REM, 10.8% in NREM1, 67.7% in NREM2, 17.5% in SWS, and 0.3% in NOS. The median unbroken sleep period was 00 : 01 (range 00 : 01–00 : 59). Taking only the single longest unbroken sleep period per patient, the median was 00 : 31 (range 00 : 01–00 : 59). Conclusions: The total amount of sleep experienced by alert patients in ICU is lower than the 8 h recommended by the WHO [1]. When sleep did occur patients awoke quickly afterwards. No patient slept continuously for longer than 1 h. This cohort of recovering patients had reduced REM sleep and increased non-REM sleep relative to normal proportions [1]. which suggests they are experiencing ongoing sleep deprivation during their ICU admission.

Purpose: To compare survival and quality of life in a mixed ICU population of patients 80 years of age or older and a matched segment of the general population.


42 O15-04 Pre-ICU quality of life as predictor of post-ICU mortality in patients with critical illness neuromuscular abnormality Andrius Klimasauskas1, Ieva Sereike2, Ausra Klimasauskiene2, Jurate Sipylaite1 1 Vilnius University, Medical Faculty, Clinic of Anaesthesiology and Reanimatology, Lithuania, 2Vilnius University, Medical Faculty, Clinic of Neurology and Neurosurgery, Lithuania Introduction: The purpose of study was to determine predictive factors of post-ICU mortality in patients with critical illness neuromuscular abnormalities (CINMA). Material and methods: A prospective study was carried out in ICU of Vilnius university hospital Santariskiuz klinikos. SF-36 was used to assess the quality of life (QOL) before treatment in ICU. Presence of CINMA was diagnosed by electroneuromyography at discharge from the ICU. Predictive factors of post-ICU mortality of CINMA patients were determined. Results: 111 subsequent ICU survivors were included in to the study. CINMA was diagnosed in 50 patients (44.7%). CINMA patients were older, they APACHE-II, SOFA, SAPS-3 scores were higher in comparison with no-CINMA patients. Length of ICU stay and mechanical ventilation was longer in CINMA patients. There was no difference between QOL before ICU treatment in CINMA and no-CINMA patients groups. 6 no-CINMA and 6 CINMA patients died during 6 months period after ICU discharge. There were no differences between any of characteristics of dead no-CINMA patients and no-CINMA survivors. There were no differences between any characteristics of dead CINMA patients and survivors, except physical function (PF) and role physical (RP). PF and RP before treatment in ICU of died CINMA patients was worse in comparison with CINMA survivors (48.3 35.3 vs 74.8 22.3; P = 0.045 and 32.3 28.1 vs 62.4 27.6; P = 0.033). PF and RP thresholds of higher mortality was 40 points. Conclusions: Low RP and PF before treatment in ICU associated with higher post-ICU mortality of patients with CINMA and could be the predictor of worse outcome.

recommendation). Also, we suggest early use of neuromuscular blocking agents (NMBAs) in patients with severe ARDS (weak recommendation, moderate quality evidence). We recommend against the routine use of all other drugs, including corticosteroids, beta2 agonists, statins and inhaled nitric oxide (iNO) in adults with ARDS (strong recommendation; low to high quality evidence). These recommendations do not preclude the use of any drug or combination of drugs targeting other underlying or co-existing disorders. The use of rescue therapies in immediately life-threatening hypoxemia will be addressed separately. Conclusion: We suggest fluid restriction in all adults with ARDS and suggest early use of NMBAs in severe ARDS. We recommend against the use of all other drugs in the routine management of ARDS.

O15-06 Long-term mortality of individuals with inhospital acute kidney injury Thorir Einarson Long1, Martin Ingi Sigurdsson2, Olafur Skuli Indridason1,3, Gisli Heimir Sigurdsson1,4 1 Faculty of Medicine, University of Iceland, Iceland, 2Brigham and Women’s Hospital/Harvard medical School, United States of America, 3 Division of Nephrology, Landspital University Hopital, Iceland, 4 Department of Anesthesia and Intensive Care, Landspital University Hospital, Iceland Introduction: We studied long-term mortality of individuals with in-hospital AKI (hAKI) and compared trends in mortality and renal recovery over 20 years in a large population-based cohort. Methods: We reviewed all serum creatinine (SCr) measurements at Landspitali University Hospital 1993–2013. We defined hAKI into stages 1, 2 and 3 based on a ratio of highest (during hospitalization) and baseline SCr of 1.5–1.99, 2.0–2.99 and ≥ 3. We used ICD9/10 codes to classify comorbidities, and baseline SCr to estimate glomerular filtration rate (eGFR). We compared survival of

O15-05 Scandinavian clinical practice guideline on fluid and drug therapy in adults with the acute respiratory distress syndrome Jon Henrik Laake1, Jonas Claesson2, Morten Freundlich3, Ivar Gunnarsson4, Per Olav Vandvik5, Tero Varpula6, Tor Aksel Aasmundstad1 1 Rikshospitalet – Oslo University Hospital, Norway, 2Department of Intensive Care, Ume a University Hospital, Sweden, 3Aalborg University 4 Hospital, Denmark, Landspitali University Hospital, Iceland, 5 University of Oslo, Norway, 6Helsinki University Hospital, Finland The objective of the Scandinavian society of anaesthesiology and intensive care medicine (SSAI) task force on fluid and drug therapy in adults with the acute respiratory distress syndrome (ARDS) was to formulate treatment recommendations based on available evidence from systematic reviews and randomised trials. Methods: The guideline was developed according to standards for trustworthy guidelines through a systematic review of the literature and the use of the GRADE system for assessment of the quality of evidence and for moving from evidence to recommendations in a systematic and transparent process. Results: We found evidence of moderately high quality to support a suggestion of fluid restriction in patients with ARDS (weak

Fig. 1 Survival of individuals with in-hospital Acute Kidney Injury (AKI) compared with a propensity score matched control group Source: https://www.eventure-online.com/parthen-uploads/154/SSAI/img1_264994_XOqfJ2aHSe.png


43 the hAKI group with a propensity score matched group, matching on age, gender, comorbid diagnoses, eGFR and year of diagnosis. Renal recovery was defined as SCr less than 1.5-fold baseline within a year of hAKI. Results: Of 25.274 individuals with available baseline SCr, 10.419 (41%) had hAKI, 19%, 11% and 12% with stage 1, 2 and 3, respectively. Individuals with hAKI were significantly older, had worse baseline eGFR and a higher ratio of them had ischemic heart disease and cancer. Long-term survival was significantly worse for individuals with hAKI with HR of 1.80, 2.16, 2.51 for hAKI stage 1, 2 and 3 compared to the propensity score matched control group. One year after hAKI, 97%, 91% and 85% of surviving patients had achieved renal recovery for stage 1, 2 and 3, respectively. Long-term survival and renal recovery for stage 3 hAKI improved over time. Conclusions: hAKI is a strong independent predictor of long-term mortality. Survival and renal recovery increased over time, indicating improved treatment.

O15-07 Identification of novel candi date risk genes for atrial fibrillation after cardiac surgery using highthroughput rna sequencing of human left atrium tissue Martin Ingi Sigurdsson, Mahyar Heydarpour, Louis Saddic, Tzuu-Wang Chang, Stanton K. Shernan, Jochen Danny Muehlschlegel, Simon C. Body Brigham and Women’s Hospital/Harvard Medical School, United States of America Introduction: By analysing of tissue-specific gene expression in the human left atrium (LA), we sought to find novel genes and explain previously known gene associations. Methods: We obtained samples from the LA free wall in 64 Caucasian patients undergoing mitral valve surgery. We sequenced RNA isolated from the LA samples using 90 bp paired end sequencing on Illumina HiSeq 2000. We aligned the reads to the human genome and list of human genes, and compared gene expression Table 1 Patient characteristics. Genes with differential expression in left atrium between patients who developed atrial fibrillation and controls. Source: https:// www.eventure-online.com/parthen-uploads/154/SSAI/img1_264993_XOuVnIofL8.png.

between patients who developed poAF and those who did not. We also correlated gene expression with the genotyping of 35 SNPs previously associated with AF. Results: A total of 22 patients (34%) developed AF after surgery. The patients who got AF were older and were more likely to have hypertension and usage of statins. LA volume and bypass times were comparable. We found 19 genes with significantly different expression between patients with and without AF after correcting for multiple testing. These include genes coding for potassium channels (KCNA7), and genes associated with cardiac hypertrophy (OGN) not previously associated with AF. There was not a significantly different expression between cases and controls of the PITX2, KCNN3 and ZFHX3 genes previously associated with AF. We found a highly significant association between the rs6795970 SNP and the expression of the SCN10A sodium channel. Conclusions: We have identified multiple novel candidate genes for AF and and provided further explanation the effects of previously known risk alleles involved in AF pathogenesis.

O15-08 The epidemiology of mechanical ventilation in Iceland Elin Bjo¨rnsdottir1, Kristinn Sigvaldason1, Martin Ingi Sigurdsson2, Alma D. Mo¨ller1, Asbjo¨rn Blo¨ndal3, Gisli H. Sigurdsson1,4 1 Department of Anesthesia and Intensive Care, Landspitali University Hospital, Iceland, 2Brigham and Women’s Hospital/Harvard Medical School, United States of America, 3Deaprtment of Anesthesia and Intensive Care, Akureyri, Hospital, Iceland, 4Faculty of Medicine, University of Iceland, Iceland Background: Mechanical ventilation (MV) is a life-sustaining intervention in ICU but data on the epidemiology of MV is limited. The purpose of this study was a population based review of all admissions needing MV in Iceland during a 5 year period. Methods: Admission databases in all intensive care units in Iceland were retrospectively reviewed, analyzing the incidence, patient characteristics, treatment and outcome of patients requiring MV. Results: During the study period, 3075 patients needed MV on average for 3.9 days and average length of ICU stay 5.2 days. Males were 66% and the average age was 59 years. The 30 day mortality rate was 18.6%. The most common indications for MV were respiratory diseases, heart diseases, CNS diseases, trauma, sepsis and major surgical operations. Tracheostomy was performed in 235 patients (7.6%), 34 patients (1.1%) needed high frequency oscillatory ventilation (HFOV), 24 prone position (0.78%) and 22 needed ECMO (0.72%). Duration of MV was one day or less in 62% of patients, most often following major surgery with a 30 day mortality rate 11.7% but 30% for those requiring more than two days of MV. Long-term outcome depended on age and underlying disease. Logistic regression analysis adjusting for age, gender and admission diagnosis shows that risk of death increased by 1% for each day on MV. Conclusion: Nearly half of all patients admitted to intensive care units in Iceland need mechanical ventilation. Long-term outcome is dependent on age and underlying disease and with logistic regression analysis, duration of MV becomes significant.


44 O15-09 On-call physiotherapists’ clinical reasoning and decision making when mobilizing critically-ill patients: a qualitative study

€ Ol of Ragna Amundad ottir1,2, Helga Jonsdottir2, Þorarinn Sveinsson2, Alma D. M€ oller1, Elizabeth Dean2,3, Gısli Heimir Sigurðsson1,2 1 Landspıtali University Hospital, Iceland, 2University of Iceland, School of Health Sciences, Iceland, 3University of British Columbia, Faculty of Medicine, Vancouver, Canada Introduction: Although early mobilization is an evidence-based intervention for critically-ill patients, clinical reasoning and decision making processes used by physiotherapists to maximize its effectiveness warrant elucidation. This study’s aim was to describe physiotherapists’ clinical reasoning processes that guide their decision making when mobilizing patients in the intensive care unit. Methods: A purposive sample of on-call physiotherapists (n = 12), working at Landspıtali, University Hospital in Reykjavık, participated in a multiple case study. Participants had a mean time from graduation of 10.9 y 10.4 SD and on-call experience at Landspıtali of 8.3 y 9.2 SD. Data collection consisted of the primary investigator’s observing each participant mobilize a critically-ill patient and recording notes. She then conducted a semi-structured interview with each participant about her/his clinical reasoning and decision making processes. Established qualitative research method for extracting themes and sub-themes was used in the analysis. Results: Preliminary results suggest themes associated with physiotherapists’ deciding to mobilize include patient status, team consultation, barriers and solutions; and with selecting the type of mobilization and its parameters (intensity and duration), themes included patient status and safety. Conclusions: Clinical reasoning and decision making processes used by the on-call physiotherapists in this study when mobilizing critically-ill patients are multi-faceted. These processes are deliberate, goal-oriented and tailored to each patient’s individual needs. They include personal, professional and institutional factors. Knowledge of such factors not only sheds light on processes typically used by physiotherapists in mobilizing critically-ill patients, but also helps inform how these processes can be taught to students.

Free Paper Session 16 – Procedures O16-01 Reduction of peri-operative neurological complications during ultrasound-guided central venous catheterization Yusuke Kasuya1, Yusuke Asakura2, Maho Kinoshita1, Kotoe Kamata1, Makoto Ozaki1 1 Tokyo Womens’ Medical University, Japan, 2Nagoya Kyoritsu Hospital, Japan Introduction: Carotid plaques are frequently seen in patients who have suffered from an episode of stroke. Thrombus formed on atherosclerotic plaques may migrate and embolize the intracranial arteries, resulting in artery-to-artery embolic cerebral infarction. Recently, ultrasound guidance for central venous catheterization has gained in popularity, and it has been shown to reduce the time required for catheterization, and the rate of complications. During the ultrasound-guided internal jugular venous catheterization, the presence of carotid plaques was simultaneously evaluated.

Methods: We routinely started to evaluate the carotid artery simultaneously. After an IRB approval, twenty patients who had undergone any surgical procedures in our facilities in October, 2012, were retrospectively evaluated (male14, female 6, median age 67(range: 46–82)), retrospectively. Additionaly, peak stroke velocity and end diastolic velocity were measured. Results: Twelve patients were diagnosed as having carotid plaques and four patients as having carotid stenosis. In some of the cases, they are highly likely to develop cerebral infarction. In this 66-year-old male (Fig. 1), ultrasonic morphology was heterogenous, consisting of the hypoechoic and echolucent parts, and the ulceration of the plaque was apparent. These parts are highly associated with the increased risk of stroke. Additionally, peak stroke velocity was 1.49(m/s), whichi suggests the increased likelihood of the development of cerebrovascular complications. Discussion: We suggest the significance of evaluating the carotid artery during the ultrasound-guided central venous catheterization. Particularly, the assessment of the morphology of the plaque is of the particular importance.

Fig. 1. Source: https://www.eventure-online.com/parthen-uploads /154/SSAI/img1_257929_odOZcpA40k.jpg

O16-02 Is Trendelenburg position the only way to visualize internal jugular veins better? Sarunas Judickas, Dalia Gineityte, Greta Kezyte, Ernestas Gaizauskas, Mindaugas Serpytis Vilnius University, Lithuania Introduction: Larger cross-sectional area (CSA) of internal jugular vein (IJV) makes catheterization easier and Trendelenburg position is used to achieve this. Unfortunately it is not comfortable for conscious patients. Aim: To identify alternative maneuvers that significantly increase cross-sectional area of internal jugular veins. Methods: A prospective study of 63 healthy volunteers took place from 2014 11 06 to 2015 01 21. Two-dimensional ultrasound images of right IJV (RIJV) and left IJV (LIJV) were recorded at the level of cricoid cartilage in a supine position with head rotated by 30-degrees during: resting inspiration hold, hold of deep breath, resting and forced expiration hold, abdominal compression of 10 kg, 30-degree bed head elevation, 45-degree leg lift and 10-degree Trendelenburg position. Results: CSA of RIJV and LIJV significantly increased using hold of deep breath (mean size (cm2)) RIJV 1.59 0.82, LIJV 1.07 0.64; both P < 0.001), Trendelenburg position (mean size (cm2)) RIJV 1.5 0.68, LIJV 0.99 0.54; both P < 0.001). 45-


45 degree leg lift increased CSA only of RIJV (mean size (cm2)) 1.17 0.61, P = 0.024). These maneuvers were compared with Trendelenburg position. There was no significant difference in size of CSA using hold of deep breath on LIJV (P = 0.08) and RIJV (P = 0.203), leg lift had a significantly weaker impact on size of CSA (P < 0.001 both sides). Conclusions: Hold of deep breath and 45-degree leg lift (the later limited for right side only) are alternative maneuvers to improve visualization of internal jugular vein for conscious patients. Hold of deep breath was as effective as Trendelenburg position.

O16-03 Effect of compression distal to cannulation site on the success rate during the radial artery cannulation Taewan Lim, Mingi Son, Euiyong Shin, Daun Oh Hallym University Dongtan Sacred Heart Hospital, South-Korea Introduction: the radial artery is the most common site for realtime blood pressure monitoring during general anesthesia. if blood pressure of the radial artery cannulation site could be increased by compression distal to cannulation, we intuitively thought that the success rate of the radial artery cannulation would be increased. this prospective randomized study was aimed to evaluate if compression distal to cannulation site may increase the success rate for the radial artery cannulation. Methods: 52 patients requiring the radial artery cannulation were enrolled. they were randomized either to group a (with compression) or group b (without compression). after general anesthesia, the patient’s arm was placed on the arm board, with 50-ml syringe under the wrist. 20-gauge venous catheter was inserted by conventional technique. in the group a, compression was performed at the wrist crease with enough pressure to occlude radial artery flow and cannulation was performed 3 cm proximal to the compression site. a Fisher exact test was used for comparison of the cannulation failure. a P-value of < 0.05 was considered to be statistically significant. Results: in the group a and b, the cannulation failure occurred in 1 of 26 patients and 8 of 26, respectively. the incidence of failure significantly decreased in the group a (P = 0.011). Conclusions: this study demonstrates that distal compression to cannulation site during the radial artery cannulation may increase the success rate.

O16-04 Video laryngoscope assisted asleep oral fibreoptic intubation Senthil Nadarajan Ipswich hospital, United Kingdom Introduction: Videolaryngoscopy(VL) improves glottic view in potentially difficult airways. However, failed intubations are possible with angulated blade VL, even with the use of a preformed rigid stylet. The use of fibreoptic laryngoscope as a flexible stylet has been reported to assist intubation in such cases(Moore & Wong, 2007).1 This case report describes the successful management of a difficult airway in a morbidly obese patient. Patient & Methods: A 50-year-old female with a BMI of 42 and a history of sleep apnoea, was scheduled for a gastroscopy and colonoscopy. Preoperative airway assessment predicted difficult airway with a Mallampatti grade 4, reduced neck extension and inability to protrude the lower incisors beyond the upper incisors. The initial tracheal intubation plan was asleep intubation using McGrathâ Series 5 videolaryngoscope under total intravenous anaesthesia.

Results: Mask ventilation was possible on induction of general anaesthesia. VL provided a Cormack and Lehane grade-2b view. Attempts at intubation guided by a rigid stylet and bougie were unsuccessful. Fibreoptic intubation was attempted, through a supraglottic airway without success. A repeat VL was performed and a second operator achieved fibrescope-guided intubation with ease. Conclusions: Videolaryngoscopy facilitates asleep oral fibreoptic intubation in this morbidly obese patient with anticipated difficult airway. References: [1] Moore MS, Wong AB. GlideScope intubation assisted by fiberoptic scope. Anesthesiology 2007; 106: 885.

O16-05 Effect of modified jaw thrust maneuver on tracheal intubation using a lightwand Jin-Young Hwang1, Jee-Eun Chang2, Hyerim Kim2, Chong-Soo Kim2, Seong-Won Min2 1 SMG-SNU Boramae Medical Center, South-Korea, 2SMG-SNU Boramae Medical Center, South-Korea Background: A lightwand is an effective and usuful device for tracheal intubation, and has been widely used in the clinical practice. We evaluated the effects of conventional and modified jaw thrust manoeuvers on lightwand search time, number of intubation attempt, intubation time, and hemodynamic changes in patients undergoing orotracheal intubation using a lightwand. Methods: Forty-two adult patients were included. After induction of anesthesia, intubation using a lightwand was performed under conventional (n = 21) or modified jaw thrust (n = 21) maneuvers. In the conventional group, the lightwand was inserted with the right hand after the mandible was lifted by putting a thumb of the left hand into the mouth. In the modified group, while jaw thrust was achieved by an assistant, the lightwand was inserted. Lightwand search time (time from insertion of lightwand to the moment of transillumitaion over the cricothyroid membrane), number of intubation attempts, and time to achieve intubation were recorded. Heart rate and mean arterial pressure were measured before and after intubation. Results: Lightwand search time were significantly shorter in the modified group compared to the conventional group (4.6 [1.1] s vs. 6.7 [2.2] s, mean [SD], respectively; P = 0.001). The modified group had shorter intubation time than the conventional group (10.0 [2.0] s vs. 13.5 [3.1] s, respectively; P < 0.001). Number of intubation attempt, and hemodynamic changes after intubation were similar between the two maneuvers. Conclusions: The modified jaw thrust maneuver reduced lightwand search time and intubation time during a lightwand-guided tracheal intubation compared to the conventional one.

O16-06 Evaluation of the performance of the AmbuⓇ ScopeTM3 slim for Single Lung Ventilation procedures Annette Ulrich, Dennis Bigler, Niels Erik Ove Andersen Rigshospitalet, University of Copenhagen, Denmark The Ambuâ aSopeTM3 Slim is a disposable endoscope with an insertion cord measuring 3.8 mm outer diameter, 60 cm length and suction channel of 1.2 mm. The system comes with a portable, touch screen monitor, Ambuâ aView, which provides a high-reso-


46 lution image and allows the recording of video sequences and images. All these properties together with the portability and availability would make the Ambuâ aSopeTM3 Slim a viable alternative to multiple use endoscopes. The evaluation by 3 independent, experienced clinicians has demonstrated that the Ambuâ aScopeTM3 Slim performs well when used for elective placement of DLTs and BB. Interestingly, the endoscope was compatible with DLT FR35 and despite its relative narrow suction channel (1.2 mm) suction capacity was assessed as satisfactory in this evaluation. DLT and BB placement was satisfactorily done in all 39 cases suggesting that the mechanical performance of the device and its image quality are sufficient for SLV procedures like the ones incorporated in this series. We conclude that the image quality and secretion removal capacity, the single-patient resourcing, and lack of repair costs and inconveniences make the incorporation of the Ambuâ aSopeTM3 Slim a practical and attractive alternative to the traditional flexible Scopes for SLV procedure

Free Paper Session 17 – General Anaesthesia I O17-01 Effects of remifentanil on pharyngeal swallowing: a double blind, randomized, cross-over study in healthy volunteers Johanna Savilampi, Rebecca Ahlstrand, Anders Magnuson € Orebro University, Sweden Background: Exposure to remifentanil causes swallowing difficulties and increases the incidence of pulmonary aspiration in healthy volunteers. These effects may be explained by impairment of airway defence mechanisms and/or altered swallow function. Automated impedance manometry pressure-flow analysis (AIM analysis) is a technique that allows objective assessment of swallow function based on pressure-impedance patterns recorded during bolus swallowing. The aim of this study was to use AIM analysis to quantify the effect of remifentanil on pharyngeal swallowing in both young and old volunteers and to compare these effects with morphine. Methods: Eighteen healthy young and old volunteers participated in a double-blind, randomized, cross-over trial at the University ~ Hospital in Orebro, Sweden. Subjects were studied on two occasions during which they received either target-controlled infusion of remifentanil (young: 3 ng/ml, older: 2 ng/ml) or a bolus injection of morphine (young: 0.1 mg/kg, older: 0.07 mg/kg). Pressureimpedance measurements were made with an indwelling catheter and ten liquid swallows were captured during each measuring condition. The pressure-flow variables defining swallow function were calculated and compared to determine drug effects. Results: Remifentanil influenced the variables towards the direction that is consistent with greater swallow dysfunction. Vigor of the pharyngeal contraction was weakened, pharyngeal bolus propulsion was diminished, and flow resistance was increased. The swallow risk index, a global index of swallowing dysfunction, increased overall. Similar effects were found with morphine but the impact of remifentanil was greater. Conclusions: Remifentanil over morphine induced dysfunction of pharyngeal swallowing; this may contribute to the elevated risk of aspiration.

O17-02 Effect of intraoperative remifentanil infusion on immediate postoperative pain in patients underwent thyroidectomy Doo Hwan Kim, Seong-Soo Choi Asan Medical Center, South-Korea Introduction: Remifentanil is a potent ultra-short acting synthetic opioid which can be applied to various groups of patients regardless of hepatic and renal condition. Opioid-induced hyperalgesia is regarded as a problem of intraoperative remifentanil infusion. This retrospective study aimed to clarify whether the remifentanil infusion causes severe pain at immediate postoperative period in patients underwent thyroidectomy. Methods: We retrospectively assessed 2021 patients aged 20 years or over who underwent thyroidectomy for 1 year between January 1, 2013 and December 31, 2013 at our institute. Every enrolled patient was divided into two groups; without intraoperative remifentanil (Group N), or with remifentanil infusion (Group R). The propensity score matching was done and 343 patients were included in each group finally. The pain scores based on Numeric Rating Scales (NRS) for pain at postoperative anesthetic care unit and at ward until postoperative 2 days were compared between two groups. Moreover, incidence of postoperative complications, such as nausea and shivering were compared. Results: NRS of pain at post-anesthetic care unit was 4.4 2.1 in group N and 6.4 2.2 in group R (P < 0.001) and there was no statistically significant difference of NRS at ward between two groups. Also, compared to Group N (73.6%), postoperative nausea was more frequent in group R (87.6%) despite of anti-emetics (P = 0.001). Conclusion: Remifentanil-based anesthesia can cause opioidinduced hyperalgesia, at least, during immediate postoperative period in patients underwent thyroidectomy. Also, intraoperative remifentanil infusion is related with more incidence of postoperative nausea and vomiting.

O17-03 Volatile anaesthetic agents and Pharmacoeconomics Biju Peringathara, Yang Ng, Nia Griffith, Maggie Gregory Southmead Hospital, United Kingdom Introduction: Volatile agents are a major part of our anaesthetic consumable expenditure. In view of the current economic climate and financial constrictions, savings in inhalational agent use were required. We conducted an audit to identify Anaesthetists’ preferences of inhalational agents and Fresh Gas Flows (FGF) used during anaesthesia. We then performed a re-audit following interventions to encourage low FGFs and the use of more economical volatile agents. Method: A survey was sent to Anaesthetists in a tertiary hospital in Bristol. We asked for preferred inhalational agents used during induction and maintenance, and the preferred FGF used during maintenance of anaesthesia. We also asked anaesthetists about their perceived costs of the inhalational agents. In the re-audit, theatres were visited to observe FGFs and agents used during anaesthesia. Result: We received 28 responses in the initial survey. Majority preferred Sevoflurane for induction and Desflurane for maintenance. The average preferred FGF was 0.6 l/min. The usage of Isoflurane in our hospital has reduced significantly over the past few years. Following intervention, our re-audit demonstrated an


47 improved average FGF of 0.4 l/min, with appropriate choices of volatile agents. Conclusion: Room for improvement is still present to reduce FGFs to our target of 0.2–0.25 l/min, which is the ‘metabolic flow rate’. More encouragement is also needed for the usage of more economical agents (i.e. Isoflurane) particularly during inductions where high flows are needed. Huge potential savings could be made with the above simple practical measures.

Fig. 1. Cue. Source: https://www.eventure-online.com/parthenuploads/154/SSAI/img1_265049_5bHksMhywT.png

O17-04 Use of Sugammadex in postextubation respiratory failure in a patient already reversed with Neostigmine and Glycopyrronium Somi Ramachary Desikan, Maria Khan East Surrey Hospital, United Kingdom Introduction:We describe a case report of use of Sugammadex (Bridion) in a patient with postextubation respiratory failure who was already reversed with neostigmine and glycopyrronium Methods: 80 year old female patient had emergency laparoscopic appendicectomy under GA.PMH of note BMI 35.1 & CKD with eGFR 57.She had modified rapid sequence induction with propofol and 50 mg rocuronium. Anaesthesia was maintained with sevoflurane and the patient was ventilated with pressure control and PEEP.She had 100 lg of fentanyl around induction and required no further opiates. Last dose of rocuronium was 45 min prior to end of operation. The operation was completed laparoscopically without any complications. Results: At the end of operation, a peripheral nerve stimulation showed four twitches with some fade.The patient started to breath spontaneously prior to the administration of neuromuscular blockade reversal of 2.5 mg neostigmine and 0.5 mg glycopyrolate.After reversal patient had 4 twitches with no fade.After extubation there was inadequate breathing with desaturation, hence another dose of neostigmine and glycopyrollate was given. Inspite of assisted ventilation oxygenation was inadequate. After ruling out other causes we gave 100 mg sugammadex to reverse any residual neuromuscular blockade from rocuronium.Within 1 min the patient’s tidal volume increased, saturation improved and see-saw breathing settled. The patients saturations remained stable in recovery and ward. There were no postoperative complications. Conclusions: Post extubation respiratory failure can occur inspite of presence of 4 twitches and apparently full reversal with neostigmine. Use of sugammadex should be considered in such situations and it can be life saving.

O17-05 Regional reversal of rocuronium-induced muscle relaxation – a pilot study

Walter Helmut Pl€ochl, Thomas Hamp, Marlene Mairweck, Judith Schiefer, Mario Krammel, Eleonore Pablik, Michael Wolzt Medical University of Vienna, General Hospital, Austria

Introduction: We hypothesized that regional reversal of rocuronium-induced muscle relaxation might be possible using sugammadex in a similar way local anesthetics are used for intravenous regional anesthesia. This might aid to detect awareness during general anesthesia or monitor motor function in certain body parts of otherwise paralyzed patients. Methods: After induction of anesthesia patients received 0.6 mg/ kg rocuronium intravenously. A tourniquet around one arm was then inflated to prevent blood supply to the arm and a small dose of sugammadex was injected into a vein of the now isolated forearm. Muscle relaxation was quantified with the train of four (TOF) in the isolated forearm and the remaining body. First a dose-titration of sugammadex was performed in 10 patients and in further 10 patients the effect of this dose was observed. Results: The dose of sugammadex to reverse muscle relaxation in the isolated forearm was 0.03 mg/kg in 30 ml 0.9% saline. Reversal of muscle relaxation in isolated forearms was completed within 3.2 min in 9 of 10 patients, while the rest of their body remained still paralyzed. Releasing the tourniquet 15 min later did not affect the TOF in the isolated forearm but significantly increased TOF in the other arm. Conclusions: Regional reversal of rocuronium-induced muscle paralysis using a dose of 0.03 mg/kg sugammadex injected into an isolated forearm was feasible without systemic effects or adverse events. References: [1] Clapham MC. The isolated forearm technique using pancuronium. Anaesthesia 1981; 36: 642–3.

Fig. 1 Dose titration of sugammadex in the Dose-Finding-Group. Source: https:// www.eventure-online.com/parthen-uploads/154/SSAI/img1_265124_QdEkbdFlOs.jpg


48 O17-06 Comparison of acupuncture and ondansetron as treatment for postoperative nausea after cardiac surgery Margrethe Jermiin Jensen, Marianne Kjær Jensen Odense University Hospital, Denmark Introduction: Postoperative nausea (PON) is a frequently symptom in patients undergoing cardiac surgery (70%). The aim of this pilot study was to show that acupuncture in selected acupoints is as effective as conventional treatment with ondansetron. Methods: January 2014 61 patients scheduled for cardiac surgery were prospective enrolled. The results are based on PON or no PON. In case of PON patients were treated with ondansetron 4 mg IV and effect was measured. With recurrent PON ondansetron 4 mg IV were repeated and evaluated. Still having PON patients were given rescue-antiemetic – dexamethason, dehydrobenzperidol. March 2014 57 patients scheduled for cardiac surgery were prospective enrolled. Patients with PON were treated with acupuncture bilateral in P6, ST36 and LV3 for 30 min and the effect was evaluated. With recurrent PON acupuncture were repeated and evaluated. If no effect of acupuncture was experienced ondansetron 4 mg IV was used as rescue-antiemetic. Results: 70% in both groups experienced PON. With first line treatment we found no difference between ondansetron and acupuncture and the effect on PON (OR 0.44, 95 % CI (0.15–1.33), P = 0.71). With recurrent PON we found no difference between the two groups and their need for rescue-antiemetic (OR = 0.83, 95 % CI [0.34–2.04], P = 0.41). Conclusion: We demonstrated that acupuncture is as effective as ondansetron for treating PON measured on the need for rescue-antiemetic. No side effects were experienced from acupuncture.

Fig. 1. Effects of treatment with ondansetron and acupuncture. Source: https://www.eventure-online.com/parthen-uploads/154/ SSAI/img1_264200_FjqyJGRslk.jpg

O17-07 Xenon-saving low-flow anesthesia in endoscopic gynecological surgery Alexandr Viktorovich Belov, Aleksey Viktorovich Pyregov Research Center for Obstetric, Gynecology and Perinatology, Russian Federation Introduction: Gynecological endoscopy (GE) is known to have a number of special attributes: Trendelenburg position (TP), CO2 insufflation. The objectives to study xenon anesthesia attributes in GE. Methods: We performed 30 patients combined xenon-saving and 30 N2O low-flow anesthesia, 35.9 1.79 y.o, with informed consent. Surgery: conservative myomectomy, hysterectomy. Groups were comparable by the main criteria of comparison. Mean duration of operations 115.9 9.77, anesthesia 134.5 9.82 min, TP 91.5 8.66 min. Mean Xe supply 13.5 l or 5.8–7.7 l per 1 h. Xe:O2 ratio 2 : 1. Fentanyl supplemented xenon anesthesia was administered only for induction and analgesia of skin incision. Biochemical and hemostasiological patterns were accessed before and after operations.

Results: Maximum hemodynamic alterations were noted during two stages: TP and „most traumatic”: SVRI elevation by 15% in N2O comparing with Xe group, those indexes were higher the normal ones in both groups; reliable SV decrease in both groups during TP stage: by 40% in N2O and 32% in Xe group (P < 0.05), and during „traumatic”stage: by 38.5% and 12% correspondingly (P < 0.05). In Xe group we found a stimulating anesthetic effect on inotropic cardiac contractions and none of negative effect on myocardium. We may testify of an adequate and balanced Xe monoanesthesia for that type of operative intervention. Postoperative pain syndrome was moderate in Xe group. Conclusion: Xe anesthesia applied in GE has proved to be a safe, balanced and well-controlled technique having a strong analgetic component and allowing to reduce dose of fentanyl 2–3.5 times as less without any detriment to hemostasis.

Free Paper Session 18 – General Anaesthesia II O18-01 Questioning the discontinuation of long half-life oral hypoglycaemic drugs before surgery? Gurcan Gungor1, Pervin Bozkurt Sutas1, Cigdem Heyik2, Berna Asan3, Yesim Cokay Abut4, Sibel Buluc4, Ozlem Gul1 1 Cerrahpasa Medical Faculty/Istanbul University, Turkey, 2Inebolu Government Hospital, Turkey, 3Kurtalan Government Hospital, Turkey, 4 Istanbul Training and Education Hospital, Turkey Some of the oral hypoglycaemic drugs (OHD) (long half- life sulfonylurea etc.) are advised to be discontinued the day before surgery in Type II diabetic patients (1). The aim of this study is to prove that the guideline regarding discontinuation of some OHDs before surgery requires revision. Material and Methods: Twenty-three patients who were on OHD and undergoing eye surgery under general anaesthesia had participated in the study following informed consent and Ethics approval in 2012- 2015 calendar years. All patients were asked to discontinue OHD the day before surgery. Ten patients discontinued OHD and 13 patients continued despite the order to stop. HbA1c preoperatively and blood glucose (BG), arterial pressures (systolic and diastolic;SAP-DAP), heart rate (HR) and SpO2 were recorded the day before and morning of surgery, intra-operative 30th and postoperative 10th and 90th min. Student’s t test and ANOVA for repeated measurements were applied. Results: Patients’ ages were between 39–82 years and on OHD for 1–20 years. There were no significant differences in HbA1c, BG, SAP-DAP, HR and SpO2 between groups Table 1. Conclusion: The fluctuations in blood glucose were significant in patients stopping OHD the day before minor surgery. The fear of hypoglycaemia is not proved so that long half-life OHDs should not be interrupted prior to surgery.

Source: https://www.eventure-online.com/parthen-uploads/154 /SSAI/img1_264518_CsUq2P2Awg.jpg


49 1. Bergman S. Perioperative management of the diabetic patient. OralSurgOralMedOralPatholOralRadiolEndod.2007;103:731

O18-02 Postanaesthesia care unit as a temporary admission location Leila Niemi-Murola, Anna-Maria Troberg, Tomi Niemi, Irma Jousela University of Helsinki, Helsinki University Hospital, Finland Introduction: Some postoperative patients stay in the postanaesthesia care unit (PACU) for extended observation. The purpose of this retrospective study was to profile these patients causing a considerable work load in the PACU. Methods: In Helsinki University Hospital, Meilahti the duration of extended observation is defined as 8 h. Two busiest months in the PACU (July = 45 and November = 42 patients needing extended observation) and two calmest months (April = 33 and December 35 patients) were included in the study. The data was extracted from the electronic patient files (PICIS, Miranda). Results: Mean duration of the prolonged observation was 17.6 h (SD 13.0). Third of the patients were classified as ASA III and 45% were ASA IV and 98% had undergone emergency surgery. One third had undergone vascular surgery and 37% had had gastrointestinal operation. The reasons for prolonged observation were oliguria, unstable hemodynamics and respiratory insufficiency, 40% of patients has all these symptoms. From the PACU, 65% of the patients were transferred to a ward and 37% were eventually discharged at home. Only 6% were explicitly classified as non-eligible to intensive care unit. In 52% of the cases, there were no text in the patient records. Conclusions: Patients needing prolonged observation in the PACU are often demanding because of their unstable condition. Despite their poor preoperative health status, the prognosis is good. Prior to the emergency operation, their postoperative care unit should be more explicitly determined in order to avoid unplanned workload to PACU.

O18-03 Computerized screening for peri-operative risk factors in the Preoperative Assessment Clinic of a tertiary university hospital: First results after implementation into clinical routine Bruno Neuner1, Finn Radtke1, Christoph Rosenthal2, Henning Krampe2, Claudia Spies2 1 Charite – Universit€atsmedizin Berlin, Germany, 2Charite – Universit€atsmedizin Berlin, Germany Introduction: To analyze in a preoperative assessment clinic feasibility and primary results of a computerized assessment of behavioral and psychological risk factors in adult elective surgery patients. Methods: Between January and June 2014 and after approval of the local data protection officer screening questions deriving from the Post-operative Quality of Recovery Scale, PQRS, regarding pain, nausea, well-being, anxiety, and questions on substance use were administered. In case of a positive screen further standardized questionnaires were added. Results: From January till June 2014, one study nurse could cover 74 / 95 working days (77.9%). Overall 1271 / 2799 (45.4%) patients were screened with 1235 (98.8%) complete screenings. Overall 517 (41.9%) screened positive regarding pain, of these 75 (6.1%) with

VAS-scores ≥ 75 points, indicating severe pain; 60 (4.9%) positive regarding nausea (of these 6 [0.5%] with an ‘orange score’ and 5 [0.4%] with a ‘red score’ in the Short Nutritional Assessment Questionnaire, SNAQ); 322 (26.1%) positive regarding impaired wellbeing (of these 41 [3.3%] with < 7 points in the WHO-5 well-being index, indicating depressive disorder); and 424 (34.3%) positive regarding anxiety (of these 29 [2.3%] ≥ 6 points in the Patient Health Questionnaire-4, PHQ-4, indicating anxiety or depressive disorder). Binge drinking and illicit drug use was reported by ~5% of patients. Conclusion: A routine computerized 2-stage-screening in a preoperative assessment clinic is feasible. Around 6% of patients report severe pain, 1% present symptoms related to malnutrition, 3% report symptoms indicative for depressive disorders and 2% symptoms indicative for anxiety disorders.

O18-04 Major complications and mortality at 90 days following minimally invasive esophagectomy (MIE) for esophageal adenocarcinoma

Kaisa Anitta Nelskyla€1, Emmi Ylikoski2, Jari R€as€anen2, Juha T. Kauppi2, Jarmo Salo2 1 Helsinki University Hospital, Finland, 2Helsinki University and Helsinki University Hospital, Finland Introduction: Adenocarcinoma is the most common type of esophageal cancer in the Western countries. The survival has increased in operable mucosal and locally advanced tumors, especially with preceding neoadjuvant chemotherapy. The aim of this study was to analyze the factors behind 90 days mortality. Methods: We analyzed retrospectively data of patients undergoing MIE due to esophageal adenocarcinoma between VIII/2009 and XI/2014 in Helsinki University Hospital. The recovery and hospital dispatch we carefully followed, as well as morbidity up to 30 days and mortality up to 90 days. Results: Data from 75 patients was collected.At30 days mortality was 1% (one patient) and at 90 days 4% (3 patients). Patient characteristics are presented in Table 1. The cardiovascular performance was well preoperatively evaluated for patient No 1 and no alarming signs were marked. The cause of death was intraoperative pulmonary embolism. Patient No 2 was acidotic preoperatively (pH 7,2/BE-18) and kidney failure requiring RRT developed. The recovery was further compromised by leakage, pneumonia, minor pulmonary embolism and sick sinus syndrome. Patient No 3 recovered well and was discharged within 13 days. The patient died of bilateral neutropenic pneumonia due to postoperative cytostatic medication. Patient No 4 suffered from serious ventilation and oxygenation problems throughout perioperative period. The patient died of ARDS and consecutive fibrosis of the lungs. Discussion: Despite MIE technique is still connected major complications and mortality up to 3 months postop which can be difficult to predict based on preoperative parameters. Mortality is mainly connected to pulmonary complications.

Source: https://www.eventure-online.com/parthen-uploads/154/S SAI/img1_263635_ffb3fhpcV2.jpg


50 O18-05 Postoperative shoulder pain after laparoscopic hysterectomy with deep neuromuscular blockade and low intraabdominal pressure -a randomised controlled trial 1

1

2

Anne Kathrine Staehr-Rye , Matias Vested Madsen , Olav Istre , Henrik Halvor Springborg2, Jørgen Lund2, Jacob Rosenberg1, Mona Ring G€ atke1 1 Herlev Hospital University of Copenhagen, Denmark, 2Aleris-Hamlet Hospitals Copenhagen, Denmark Background: Postoperative shoulder pain remains a significant problem after laparoscopy. Pneumoperitoneum with insufflation of CO2 is speculated to be the most important cause. Reduction of pneumoperitoneum may, however, compromise surgical overview. Recent studies indicate that use of deep neuromuscular blockade (NMB) improves surgical conditions during a lower pneumoperitoneum. We aimed at investigating if low pneumoperitoneum (8 mmHg) and deep NMB compared to standard pneumoperitoneum (12 mmHg) and moderate NMB would reduce the incidence of shoulder pain (VAS > 20) and improve recovery after laparoscopic hysterectomy. Methods: The study was randomised, controlled, and doubleblinded. A total of 99 patients were included and randomised to either deep NMB and 8 mmHg pneumoperitoneum or moderate NMB and 12 mmHg pneumoperitoneum. Patients received standardised pain regimen. Pain was assessed on a 100 mm VAS scale during hospital stay and fourteen days after operation. Results: In group deep NMB and 8 mmHg pneumoperitoneum, 14 of 49 patients (28.6%) had shoulder pain during the 14 postoperative days whereas in group moderate NMB and pneumoperitoneum 12 mmHg the incidence was 30 of 50 patients (60%). Absolute risk reduction was 0.31 (95% CI: 0.12–0.48) (P = 0.002). We found no differences in area under the curve for VAS scores, consumption of opioids, incidences of nausea and vomiting, consumption of antiemetics, time to recovery, length of hospital stay, or duration of surgery.

Conclusion: Deep NMB and pneumoperitoneum 8 mmHg compared to moderate NMB and pneumoperitoneum 12 mmHg reduced the incidence of shoulder pain after laparoscopic hysterectomy.

O18-06 Importance of deep neuromuscular blockade in laparoscopic surgery Anne Kathrine Staehr-Rye1, Matias Vested Madsen1, Olav Istre2, Henrik Halvor Springborg2, Jacob Rosenberg1, Jørgen Lund2, Mona Ring G€atke1 1 Herlev Hospital University of Copenhagen, Denmark, 2Aleris-Hamlet Hospitals Copenhagen, Denmark Background: Unexpected abdominal contractions may occur during laparoscopic procedures. Use of deep neuromuscular blockade (NMB) has the potential to prevent such episodes. In this study we aimed at investigating if administration of deep NMB as compared to moderate NMB reduced the incidence of sudden abdominal contractions. Methods: This was a secondary analysis of a randomised, controlled study. A total of 110 patients scheduled for laparoscopic hysterectomy were randomised to either deep NMB and 8 mmHg pneumoperitoneum (deep NMB group) or moderate NMB and 12 mmHg pneumoperitoneum (moderate NMB group). NMB was established with rocuronium and reversed with sugammadex. Two gynaecologists registered sudden abdominal, alarms from the insufflator due to sudden increased intra-abdominal pressure, and incidences where the abdominal wall felt tight. At closure of the abdominal wall fascia, surgical conditions were evaluated on a four-point rating scale. Results: In deep NMB group no sudden abdominal contractions were detected as compared to 12 incidences in the moderate NMB group (P < 0.001) (Absolute risk reduction 0.22 (95% Confidence interval 0.11–0.34)). The insufflator alarmed in 0 vs. 10 cases (P = 0.001) in the deep and moderate NMB group, respectively. The gynaecologists registered increasing abdominal tensions in 0 vs. 8 patients (P = 0.006) in the deep and moderate NMB group, respectively. Deep NMB improved surgical conditions while suturing the abdominal fascia (P < 0.001). Conclusion: No abdominal contractions were registered if deep NMB was used during laparoscopic hysterectomy. Moreover, deep NMB improved surgical conditions while suturing the abdominal fascia.

O18-07 The effect of perioperative anesthesiologic care on pulmonary complications in minimally invasive esophagectomy (MIE) for esophageal adenocarcinoma

Emmi Ylikoski, Kaisa Nelskyl€a, Jari Ra€sa€nen, Juha Kauppi, Jarmo Salo University of Helsinki and Helsinki University Hospital, Finland

Fig. 1. Shoulder pain. Source: https://www.eventure-online.com/parthen-uploads/154/SSAI/img1_264430_xIHcmMNRAW.jpg

Introduction: MIE is a surgical technique involving thoraco-laparoscopic approach with decreased tissue trauma for esophageal carcinoma. Regardless the less invasive technique morbidity is high and pulmonary complications frequent. The goal of our study was to identify factors in the anesthesiologic perioperative care that might affect the development of pulmonary complications: pneumonia, empyema and persistent atelectasis. Methods: In this retrospective study we included patients undergoing MIE due to esophageal adenocarcinoma between VIII/2009 and XII/2014 in Helsinki University Hospital. The anesthetic tech-


51 nique included one lung ventilation (OLV), in most cases total intravenous anesthesia and epidural analgesia. To standardize the perioperative fluid balance and tissue trauma patients with conversion to either thoracotomy or laparotomy were excluded. The impact of intraoperative lung protective ventilation, anesthetic agents and fluid management to the incidence of pulmonary complications were analyzed. Results: 76 patients were included in the study. The incidence of overall complications was 57% (43/76) and pulmonary complications 37% (28/76). Mortality at 30 days was 1% (1/76). ASA classification, smoking history, FEV1%, neoadjuvant chemotherapy, epidural analgesia, tidal volumes during OLV less than 8 ml/kg, fluid therapy in OR (mean 5 vs. 5.6 ml/kg/h) or the use of volatile anesthetic had no major effect on pulmonary complications. Total length of ventilator treatment and longer extubation time after ICU admission was significantly associated with pulmonary complications P = 0.035 and P = 0.024 respectively. Conclusions: In our institute the protocol for intraoperative anesthesiologic care in MIE is standardized according to international recommendations. Our results implicate prompt respirator weaning.

O18-08 No intervention should be considered trivial in reducing anesthetic costs Jason Roman Warren1, Bhavani S. Kodali1, Martin Ingi Sigurdsson2 1 Brigham and Women’s Hospital, Harvard Medical School, United States of America, 2Brigham and Women0 s Hospital, United States of America Introduction: Our academic institution uses a significant amount of remifentanil which increases anesthetic costs. The department leaders sent an email requesting that providers use expensive anesthetics judiciously, so as to lower department anesthesia costs. Methods: In this retrospective study, we evaluated the number of cases using remifentanil, fentanyl, and sufentanil over the six months (July 1st 2013 until January 1st 2014) prior to the advisory email, and the fifty days (January 22nd 2014 until March 14th, 2014) immediately thereafter, to discover if the email advisory was effective in decreasing the use of remifentanil. Results: Remifentanil was used in 6045 out of a total of 17,380 cases (35%) before the advisory email, and was used in 1281 cases out of a total of 4986 (26%) after (P < 0.0001). Fentanyl was used in 12,224 out of a total of 17,380 cases (70%) before the advisory email, and was used in 3,616 cases out of a total of 4986 (73%) after (P < 0.0027). Sufentanil was used in 177 out of a total of 17,380 cases (1%) before the advisory email, and was used in 84 cases out of a total of 4986 (2%) after (P value 0.0001) (Table). Conclusion: The advisory email resulted in a decreased use of remifentanil, compensated by increased use of fentanyl and sufentanil.

Source: https://www.eventure-online.com/parthen-uploads/154/S SAI/img1_262931_CfjK6CxDeN.jpg

Free Paper Session 19 – Nutrition O19-01 Short term intravenous amino acid supplementation improves protein balance in critically ill patients Felix Liebau, Jan Wernerman, Olav Rooyackers Karolinska University Hospital Huddinge, Sweden Introduction: Protein catabolism in critical illness can be mitigated by nutritional support, but dose recommendations for protein feeding are based on weak evidence. Before larger clinical trials are initiated, the effects of amino acid supplementation on protein metabolism require more detailed study. Methods: We investigated the effect of parenteral amino acid supplementation on whole-body protein turnover. Patients were studied during the first week after ICU admission, both at baseline during ongoing nutrition, and during extra amino acid supplementation. A complete amino acid formula was infused over 3 h at a dose of 0.04 g/kg/h. If a patient remained in the ICU 2–4 days later, these measurements were repeated. Protein kinetics were measured using stable-isotope labeled phenylalanine and tyrosine tracers. Results: Thirteen patients were studied on the first study occasion and 7 were studied twice. Amino acid supplementation improved protein balance from negative to positive: from median 4 to +7 lmol phenylalanine/kg/h (P = 0.001) on first study day and from median 0 to +12 lmol phenylalanine/kg/h (P = 0.018) on second study day. This was caused by an increased protein synthesis (significant during the first measurement, from 58 to 65 lmol phenylalanine/kg/h, P = 0.007). Amino acid oxidation, i.e. utilization as energy substrate, did not increase during supplementation. There was a positive correlation (r = 0.80; P < 0.001) between total amino acid supply and protein balance. Conclusions: In ICU patients during the early phase of critical illness, extra parenteral amino acids infused over a 3 h period improved whole body protein balance but did not increase amino acid oxidation.

O19-02 Nutritional deficit as a Negative Prognostic Factor of Nursing Home-Acquired Pneumonia Joo-Won Min1, Chang Hyeok An2, Sang Joon Park2 1 Myongji Hospital, South-Korea, 2Myongji hospital, South-Korea Instruction: Recently, nursing home-acquired pneumonia (NHAP) is increasing and the leading cause of death among nursing home residents. However, the effect of nutritional deficit on the prognosis of NHAP is still unclear. The objective of this study is to identify the role of nutrition in NHAP mortality. Methods: Data on all patients ≥ 70 years of age admitted with NHAP in 2013 were reviewed. To evaluate nutrition status, nutrition risk score was calculated. A three-point nutritional risk score (NRS) was defined according to the presence of three nutritional factors: hypoalbuminemia (< 2.5 mg/dl), hypocholesterolemia (< 100 mg/dl) and severe lymphocytopenia (< 700 cells/ll). And the risk factors associated with 90-day mortality were analyzed using the Cox-proportional hazard model. Results: NHAP patients were 118, and patients with NRS ≥ 2 were 29 (24.6%). In the survival analysis, 90-day mortality was higher in patients with NRS ≥ 2 (P < 0.001; 55.2% in NRS ≥ 2 vs. 23.6% in NRS < 2). In the multivariable analysis, residence in Care Homes (nursing facilities without full-time physicians; HR, 2.57; 95% CI 1.12–5.88), NRS ≥2 (HR, 2.84; 95% CI 1.39–5.81), the presence of


52 structural lung diseases (HR, 5.57; 95% CI 1.43–21.64), inappropriate initial antimicrobial agents for accompanied infections (HR, 2.50; 95% CI 1.17–5.35), and high Pneumonia Severity Index score >130 (HR, 3.89; 95% CI 1.54–9.83) were associated with higher mortality. Conclusions: A high NRS ≥ 2 is a good predictor of poor outcome in NHAP.

O19-03 The incretin effect in the critically ill S.T. Nielsen1, Susanne Janum2, Rikke Krogh-Madsen3, Thomas Pj Solomon4, Kirsten Møller5 1 Rigshospitalet, Denmark, 2Bispebjerg Hospital, Denmark, 3Department of Infectious Diseases and Rheumatology, Rigshospitalet, Denmark, 4 Department of Biomedical Sciences, University of Copenhagen, Denmark, 5Department of Neuroanaesthesiology, Rigshospitalet, Denmark Introduction: Hyperglycemia is frequently observed in critically ill patients in the intensive care unit, is an independent risk factor of death, and is treated with insulin, however at a significant risk of hypoglycemia. The incretin hormone, GLP-1, appears to improve glycemia in critically ill patients, as well as in patients with type 2 diabetes (T2D), at a lower risk of hypoglycemia. Methods: During a fasting oral glucose tolerance test (OGTT) and an intravenous glucose infusion (IVGI) titrated towards identical plasma glucose levels in eight non-diabetic critically ill patients and eight control subjects, we measured plasma cytokines, insulin, incretin hormones (GLP-1 and GIP) and glucagon as well as the incretin effect, i.e. the relative reduction in total plasma insulin response to the IVGI compared to the OGTT. Results: We found the incretin effect reduced in patients (P < 0.005). Pro-inflammatory cytokines, TNF-a and IL-6, and glucagon were significantly higher in patients (P < 0.05) and remained unchanged during the interventions. Patients were insulin resistant (HOMA-IR: P < 0.05) with no change in beta-cell function (HOMAbeta: P = 0.76). The response of GIP, but not GLP-1, during the OGTT was significantly higher in patients (P < 0.05).The insulin response to the OGTT did not differ between the groups, whereas the insulin response to the IVGI was higher in patients (P < 0.05). Conclusions: We observed a reduced incretin effect in critically ill patients as previously reported in patients with T2D. Existing pharmaceutics targeting the incretin system, widely used in the treatment of T2D, might represent a potential treatment of hyperglycemia in the critically ill.

O19-04 The effect of intraoperative continuous infusion of low dose glucose on ketogenesis and postoperative insulin resistance Jun Hirokawa, Saori Sako, Sayuri Koyama, Masanori Tsukamoto, Takeshi Yokoyama Kyushu University, Japan Background and Goal of Study: We reported that intraoperative 1.5% glucose infusion suppressed ketogenesis and attenuated postoperative insulin resistance.1 Additionally, it was revealed that postoperative glucose administration at 0.08–0.09 g/kg/h suppressed ketogenesis effectively. In the current study, we investigated the effect of intraoperative glucose infusion continuously at 0.08 g/kg/h on ketogenesis and postoperative insulin resistance.

Materials and Methods: In our previous study, patients undergoing oral-maxillofacial surgery were assigned to two groups; G1 group receiving Ringer solution with 1.5% glucose and R group receiving no glucose. In the current study, a new group was prepared and compared with G1 and R. The new group G2 received continuous infusion of glucose at 0.08 g/kg/h during surgery. Blood glucose level was monitored continuously. Plasma ketone bodies were measured 4 times. Insulin resistance was quantified by glucose clamp technique using the STG-55TM before and after surgery. Results and Conclusion(s): In G2 group (n = 11), the mean blood glucose level was kept between 90 mg/dL and 120 mg/dL during surgery. The ketone bodies in G2 group were lower than those of the R group. However, they increased at 3 h after induction of anesthesia, although they were significantly higher than those of G1 group (P = 0.0007). Postoperative insulin resistance in G2 group was lower than that of R group, but higher than that of G1 group. Intraoperative glucose administration continuously at 0.08 g/ kg/h is useful to avoid hyperglycemia. However, the dose of glucose might be insufficient to suppress ketogenesis and attenuate postoperative insulin resistance. References: 1. Fujino H et al. APJCN 2014; 23: 400–7.

O19-05 Vitamin D status in critical illness

Runar Bragi Kvaran1,3, Martin Ingi Sigurdsson2, Sigurbjo€rg Johanna Skarphedinsdottir3, Gisli Heimir Sigurdsson1,3 1 University of Iceland, School of Health Sciences, Iceland, 2Brigham and Women0 s Hospital, United States of America, 3Landspitali National University Hospital, Iceland Introduction: Vitamin D deficiency has been associated with cardiovascular and respiratory diseases and its importance for musculoskeletal health is known. Studies conducted at southern latitudes showed that vitamin D deficiency is common in critical illness and is associated with prolonged hospital stay and increased mortality. The aim of this study was to research the vitamin D status in critical illness at high northern latitude location in Iceland, and its effect on mortality and hospital stay. Methods: This was a single-center prospective observational research on 102 patients admitted to Landspitali University Hospital intensive care unit in 2014. In addition to clinical data, serum 25-OH-hydroxyvitamin D (25(OH)D) was measured on two occasions following admission. The prevalence of vitamin D deficiency and its effect on mortality and hospital stay was calculated. Results: Majority of patients was males (64%) and the average age of patients was 65 years (19–88 years). The most common reason for admission was sepsis (20%), followed by bleeding (16%) and respiratory failure (15%). Patients had average APACHE II score of 19. 68% were vitamin D deficient (25(OH)D < 50 nmol/L) and only 11% reached 25(OH)D recommended for good health (> 75 nmol/L). Mean difference between separate 25(OH)D measurements was 2,3 9,9 nmol/L. Intensive care unit length of stay for average 25(OH)D < 25 nmol/L was 7.7 days and 3.9 days for 25(OH)D > 25 nmol/L (P = 0.07). Conclusion: Vitamin D deficiency is common in critical illness in Iceland and the severely deficient trend toward longer intensive care unit stay.


53 O19-06 Pharmacokinetic and Pharmacodynamic evaluation of a single dose of intramuscular cholecalciferol in critically ill adults Priya Nair1, Bala Venkatesh2, Paul Lee3, Stephen Kerr4, Domnik J Hoechter5, Goce Dimeski6, Jeffrey Grice2, John Myburgh7, Jacqueline R Center3 1 St Vincent’s Hospital, Australia, 2University of Queensland, Australia, 3 Garvan Institute for Medical Research, Australia, 4University of New South Wales, Australia, 5LMU, Germany, 6Princess Alexandra Hospital, Australia, 7George Institute for Global Health, Australia Introduction: A prospective, interventional study was undertaken to determine the effect of two doses of intramuscular (IM) cholecalciferol on serial serum 25-hydroxyvitamin-D (25-hydroxy-D) levels and on pharmacodynamics endpoints- calcium, phosphate, parathyroid hormone (PTH), C-reactive protein (CRP), interleukin-6 (IL-6) and cathelicidin (LL-37) in critically ill adults. Methods: Fifty adults with the systemic inflammatory response syndrome were randomly allocated to receive a single IM dose of either 150,000 IU (group A) or 300,000 IU (group B) cholecalciferol. Pharmacokinetic, pharmacodynamic parameters and outcome measures were collected over a 14 day period or until ICU discharge, whichever was earlier. Results: Prior to randomization, 28/50 (56%) were classified as vitamin D deficient. By day 7, 15/23 (65%) and 14/21(67%) of patients normalised vitamin D levels in group A and group B, respectively (P = 0.01) and by day 14, 8/10 (80%) and 10/12 (83%) (P = 0.004) respectively. Baseline secondary hyperparathyroidism was manifested in 28% of patients. PTH levels decreased over time with patients achieving vitamin D sufficiency at day 7 having significantly lower PTH levels (P < 0.01). Inflammatory markers (CRP and IL-6) fell significantly over the study period. Greater 25-hydroxy-D increments were significantly associated with greater LL-37 increments at day 1 and 3 (P = 0.04 and 0.004 respectively). No significant adverse effects were observed. Conclusions: A single dose of either dose of IM cholecalciferol corrected vitamin D deficiency in the majority of critically ill patients. Greater vitamin D increments were associated with early greater LL-37 increases, suggesting a possible mechanism of vitamin D supplementation in inducing bactericidal pleiotropic effects.

Free Paper Session 20 – Neuroanaesthesia and neurointensive care O20-01 Postoperative haemorrhages requiring surgical treatment in neurosurgery

Kadri Lillem€ ae1, Johanna Annika Ja€rvi€o2, Marja Kaarina SilvastiLundell1, Jussi Antinheimo1, Tomi Tapio Niemi1 1 University of Helsinki and Helsinki University Hospital, Finland, 2 University of Helsinki, Finland

Introduction: Since the incidence of postoperative haematoma (POH) after neurosurgery is variable, we aimed to characterize the incidence of POH according to the type of procedure and identify risk factors. Methods: We analysed patient data between 2010 and 2012 at the Department of Neurosurgery in Helsinki University Hospital. Data search was performed according to surgery type and included craniotomies, shunt procedures, spine surgery and implantation of spinal cord stimulators.

Results: POH requiring reoperation developed after 0.64% of procedures (n = 56/8783). The incidence was 0.55% (n = 26/4726) after craniotomy, 0% (n = 0/928) after shunting procedure, 1.05% (n = 30/2870) after spine surgery and 0% (n = 0/259) after implantation of spinal cord stimulators. POH was observed more frequently after decompressive craniectomy (7.9%, n = 7/89), cranioplasty (3.6%, n = 4/112), bypass surgery (1.7%, n = 1/60) and epidural haematoma evacuation (1.6%, n = 1/64). After spinal surgery, POH was observed in 1.1% of cervical and 2.1% of thoracolumbar operations. 64% of POH and 85% of craniotomy patients had postoperative hypertension (systolic blood pressure above 160 mmHg or lower if indicated) after surgery. The incidence of anaemia (Hb < 100 g/L), low platelet count (< 100 9 109/l) or coagulation disturbance (prothrombin time value < 70%) before primary surgery or POH evacuation was 14.5%, 17.3% or 15.1%, respectively. Poor outcome (Glasgow outcome scale class 1–3), whereas death at 6 months was detected accordingly in 41% and 22% of craniotomy patients with POH. Conclusion: POH after neurosurgery is a rare complication but associates with poor outcome after craniotomy. Identification of risk factors of bleeding might decrease the incidence of POH.

Source: https://www.eventure-online.com/parthen-uploads/154/ SSAI/img1_262948_3hnjZoxq6I.png

O20-02 The effect of tracheotomy on drug consumption in patients with acute aneurysmal subarachnoid hemorrhage Leiv Arne Rosseland1, Jon Narum1, Audun Stubhaug1, Ulf Kongsgaard1, Wilhelm Sorteberg2, Angelika Sorteberg2 1 Division of Emergencies and Critical Care, Oslo University Hospital, Norway, 2Oslo University Hospital, Norway Background: Sedation of patients with aneurysmal subarachnoid hemorrhage (aSAH) is used as a neuroprotective measure to secure adequate cerebral perfusion pressure (CPP). Tracheotomy has the advantage of securing the airway at a much lower level of distress, compared to orotracheal tube. Methods: An observational study of aSAH patients between 2001 and 2009. Sedative, analgesic and vasoactive drug doses were registered for 3 days prior to and after percutaneous tracheotomy,


54 respectively. Blood pressure, CPP, and the mode of mechanical ventilation were registered prior to and after tracheotomy. Results: 902 aSAH patients were admitted to our hospital; 74 (8%) were deeply comatose/dying upon arrival. The ruptured aneurysm was repaired in 828 patients (surgical repair 50%) and percutaneous tracheotomy was performed 182 times in 178 patients (59 men and 119 women). Percutaneous tracheotomy caused a marked decline in mean daily consumption of the analgesics/sedatives fentanyl, midazolam, and propofol, as well as the vasoactive drugs noradrenaline and dopamine. CPP was stable. Mechanical ventilatory support was reduced (P < 0.001). Conclusions: Percutaneous tracheotomy in aSAH patients leads to a significant decline in the consumption of sedative/analgesic and vasoactive drugs while clinical surveillance parameters remain stable or improve.

O20-03 The effects of dexmedetomidine on cerebral autoregulation and cerebral oxygenation in subarachnoid haemorrhage patients

Minna Johanna Kallioinen1, Ari Katila1, Teijo Saari1, Juha Gr€onlund1, Jussi Posti1, Melissa Rahi1, Minna Tallgren1, Klaus Olkkola2, Riikka Takala1 1 Turku University Hospital, Finland, 2University of Helsinki and Helsinki University Hospital, Finland Introduction: Cerebrovascular autoregulation is often impaired after subarachnoid haemorrhage (SAH) due to vasospasm and delayed cerebral ischemia. Dexmedetomidine, a selective a2-agonist, induces sedation, anxiolysis and analgesia without respiratory depression. Dexmedetomidine could be a useful sedative in patients with SAH, enabling neurological assessment during infusion. The effects of dexmedetomidine on cerebral autoregulation in patients with SAH have not been studied before and the purpose of this study was to investigate how dexmedetomidine affects static and dynamic autoregulation and cerebral oxygenation in SAH patients. Patients and Methods: Five poor grade SAH patients were recruited. Dynamic and static autoregulation was first assessed during propofol/midazolam infusion and then during three increasing doses of dexmedetomidine infusion. Autoregulation was assessed with transcranial doppler (TCD). Brain oxygen saturation (ScO2) and brain tissue oxygen tension (PbrO2) (if applicable) were also recorded. Results: There were three females and two males with a mean age of 54.6 12.6. One female patient had no temporal window and therefore her TCD data is missing. Dynamic autoregulation was slightly impaired in three measurements while it was preserved in nine measurements. As the mean flow velocity remained unchanged after 20% mean arterial blood pressure increase, static autoregulation was not impaired during dexmedetomidine infusion (Table 1). Dexmedetomidine showed no deterioration in ScO2 while in one patient we observed a decreased PbrO2.

Source: https://www.eventure-online.com/parthen-uploads/154/ SSAI/img1_265010_2XZkQurhnZ.jpg

Conclusions: Dexmedetomidine seemed to preserve autoregulation in our patients. No deterioration in brain oxygen saturation was observed despite decreased PbrO2 in one patient. Further studies with dexmedetomidine in neurologically injured patients are warranted.

O20-04 Complications in barbiturate coma therapy for refractory intracranial hypertension C T Chong1, H M Tan2, R Teh2, T Lyovarin2, Y Zeng2 1 Tan Tock Seng Hospital, Singapore, 2National University of Singapore, Singapore Introduction: Barbiturate coma therapy(BCT) though effective for refractory intracranial hypertension, remains as second-tier treatment because of associated adverse effects. Methods: Retrospective study of all patients admitted 2008–2012 for traumatic and non-traumatic brain injuries receiving thiopentone BCT for control of refractory intracranial hypertension in neurosurgical ICU (Tan Tock Seng Hospital). Results: Seventy-one patients received BCT. Traumatic brain injuries accounted for 52.1% of cases. Mean age was 43.5 13.1, with slight male-gender preponderance (57.5%). Median postresuscitation GCS was 4 (3–7) and median APACHE II score at ICU admission was 25(23–29). Mean maximum intracranial pressure prior to initiating barbiturate coma was 48.3 22.6 mmHg. Median duration of thiopentone infusion was 48.0 (22.6–78.3) h, the longest BCT duration being 285 hr. Median maximum infusion rate was 300 (250– 500) mg/h, with median total thiopentone infused being 12550 (4600–17021) mg. Noradrenaline infusion (maximum dose 0.30 0.22 lg/kg/min) for systemic hypotension upon starting BCT was required in 64(87.7%) episodes. Superimposed clinical infection occurred in 30 patients at mean onset of 3.4 2.9 days after BCT induction, with pneumonia (n = 15) and septicaemia (n = 9) accounting for the majority of infections. Hypokalemia occurred in 50(76.9%) BCT episodes; time to nadir of potassium levels (lowest mean K + 2.62 0.90 mmol/l) was at 24 hr after institution of BCT and this was associated with ventricular ectopics/arrhythmias in 38 (76.0%) of these cases. 12(16.9%) patients had rebound hyperkalaemia (6.3(5.8-6.4) mmol/l) on BCT cessation. Hypernatraemia(peak mean Na 155.3 13.3 mmol/l) occurred in 47 BCT episodes(64.4%). Intolerance to enteral nutrition occurred in 35.6% of patients. Conclusion: BCT should be employed with caution because of serious infective, hemodynamic and electrolyte perturbations.

O20-05 Prone vs. sitting position in neurosurgery – differences in patient hemodynamics and in stroke volume – directed fluid administration

Teemu Sakari Luostarinen1, Ann-Christine Lindroos1, Tomohisa Niiya2, Marja Silvasti-Lundell1, Alexey Schramko1, Juha Hernesniemi1, Tarja Randell1, Tomi Niemi1 1 Helsinki University Hospital, Finland, 2Department of Anesthesiology, Sapporo Medical University School of Medicine, Japan Introduction: General anesthesia exposes patient to hemodynamic alternations both in prone and sitting position. As the comparison of the sitting and prone position in neurosurgery is scarce, we aimed to evaluate hemodynamic profile during stroke volumedirected fluid administration in patients undergoing neurosurgery either in sitting or prone position. Methods: Thirty patients in prone and 28 in sitting position in two separate prospective trials were randomized to receive either Ring-


55 er’s Acetat (RAC) or hydroxyethyl starch (HES 130 kDa/0.4) for optimization of stroke volume. After combining data from these two trials the two-way analysis of variance (ANOVA) was performed to compare patient hemodynamic profile between the two positions and to evaluate differences between RAC and HES consumption. Results: To achieve comparable hemodynamics during surgery higher mean cumulative dose of RAC than HES was needed (678 390 ml vs. 455 253 ml, respectively, P < 0.05) However, when fluid consumption was adjusted with weight, statistical difference was lost. Fluid administration was similar weather patient was in prone or sitting position. Mean arterial pressure (MAP) was lower and cardiac index (CI) and stroke volume index (SVI) was higher overtime when patient was in sitting position. Conclusion: Sitting position does not require excess fluid treatment compared to prone position. HES is slightly more effective than RAC in achieving comparable hemodynamics, but difference might be explained by patient weight. With goal directed fluid administration and moderate use of vasoactive drugs it is possible to achieve stable hemodynamics in both position. Fig. 1 Source: https://www.eventure-online.com/parthen-uploa ds/154/SSAI/img1_258030_qoCjiqMikr.jpg

Source: https://www.eventure-online.com/parthen-uploads/154/ SSAI/img1_261919_2DnzR1IIMA.jpg

O20-06 Delayed cerebral hypoperfusion following intracranial aneurismal clipping assessed by CT perfusion; New clinical entity? Maho Kinoshita1, Yusuke Asakura2, Yusuke Kasuya1, Kotoe Kamata1, Makoto Ozaki1 1 Tokyo Womens’ Medical University, Japan, 2Nagoya Kyoritsu Hospital, Japan Introduction: Many elements of intra-operative management of intracranial anurysmal clipping may influence their outcomes. However, in cases who have successfully recovered from clipping surgery, anesthesilogists usually regard them as the standard risk. Recent advent of CT perfusion (CTP) has made it possible to directly measure the cerebral blood flow at any intracranial region of interest. We have assessed the cerebral blood flow of the patients who had undergone clipping surgery. Methods: In our facility, CTP was introduced in 2012. After an IRB approval, we have analyzed all the 58 cases that had undergone CTP in our facility, and identified 6 cases who had undergone clipping surgery. Cerebral blood flow (CBF) just distal region of the clipped artery together with MTT (mean transit time), CBV (cerebral blood volume) were evaluated, and compared with those at the contralateral hemisphere.

Results: Six cases undergone clipping surgery for ruptured aneurysm and one had undergone for unruptured aneurysm. Three were for aneurysm of midcerebral artery, one for IC-PC, one for aneurysm at the vertebral artery, and one for the aneurysm at Acom. In three out of 6 cases, there was an overt decrease of cerebral blood flow at the distal region of clipped artery. Figure shows one such a patient in whom CBF at the distal region of the clipped artery was 16.4 ml/100 g/min whereas CBF at the contralateral hemisphere was 32.7 ml/100 g/min. Conclusion: In the patients who had undergone clipping surgery previously, anesthesiologists are required to pay close attention to their blood pressure management during surgery.

O20-07 CT perfusion findings may predict a potential risk of developing cerebrovascular complications in patients with carotid arterial stenosis Yusuke Asakura1, Maho Kinoshita2, Kotoe Kamata2, Yusuke Kasuya2, Makoto Ozaki2 1 Nagoya Kyoritsu Hospital, Japan, 2Tokyo Womens’ Medical University, Japan Introduction: Neurological complications occur with an overall frequency of 2.8% perioperatively. Ultrasound imaging is an excellent modality for the risk assessment, although no comprehensive information can be obtained with respect to the intracranial cerebral blood flow. Recent advent of CT perfusion (CTP) imaging has made it possible to directly measure the cerebral blood flow at any intracranial region of interest. We have assessed its efficacy in the risk assessment of perioperative development of neurological complications. Methods: CTP imaging has been introduced in 2012, and 58 cases underwent its evaluation. After obtaining IRB approval, we have analyzed all the 58 cases, and identified 11 individuals who have been diagnosed as having carotid arterial stenosis/occlusion. We have measured CBF (cerebral blood flow), CBV (cerebral blood volume), and MTT (mean transit time) at the ipsilateral as well as at the contralateral hemisphere, and its correlation to the subse-


56 quent development of neurological events during the two year follow up period were evaluated. Results: Of 11 patients, the decreased CBF at the ipsilateral hemisphere was noted in 4 individuals, and the other 7 showed intact CTP findings. All the 4 patients who showed decreased CBF pattern and the one who showed normal CTP finding developed cerebrovascular diseases during the 2 year follow up period. The rest of 6 individuals who showed normal CTP findings have remained otherwise healthy. Conclusions: The decreased CBF at the ipsilateral side may predict the possible neurological complications in the patients with carotid arterial stenosis/occlusion.

O20-08 Ultrasound tagged near infrared spectroscopy does not express carbon dioxide reactivity in humans Anton Lund1, Niels Henry Secher1, Ai Hirasawa2, Shigehiko Ogoh2, Takeshi Hashimoto3, Henrik Winther Schytz4, Messoud Ashina4, Henrik Sørensen1 1 Rigshospitalet, Denmark, 2Faculty of Science and Engineering, Toyo University, Japan, 3Ritsumeikan University, Japan, 4Glostrup Hospital, Denmark Introduction: Non-invasive monitoring of cerebral blood flow (CBF) is of interest during anesthesia and several techniques are available. We evaluated the CerOx 3110 (Ornim Medical Ltd., Israel) that employs ultrasound tagged near-infrared spectroscopy to estimate changes in a CBF index (CFI). Methods: Seven healthy males (age 21–26 years) hyperventilated and were administered phenylephrine to increase mean arterial pressure by ~20 mmHg. Frontal lobe tissue oxygenation (ScO2) and CFI were obtained using the CerOx and mean blood flow velocity in the middle cerebral artery (MCAvmean) was determined by transcranial Doppler ultrasound. To assess an influence from extracerebral tissues, skin blood flow (SkBF) was measured by laser Doppler and skin oxygenation (SskinO2) by white light spectroscopy. Results: During hyperventilation MCAvmean decreased by 44% (median; interquartile range 40–49; P = 0.0156) as the arterial carbon dioxide was reduced by 52% (47–58; P = 0.0156). Conversely, CFI increased by 9% (2–31; P = 0.0156), while no significant change was observed in ScO2. SkBF increased by 19% (9–53; P = 0.0156) and SskinO2 by 6% (1–7; P = 0.0469). Administration of phenylephrine was not associated with significant changes in CFI, ScO2, or skin variables. Conclusions: During hyperventilation CFI demonstrated an inverse relationship to regional CBF as determined by MCAvmean. The increase in CFI during hyperventilation may be influenced by increased oxygenation in superficial tissues.

Fig. 1 Source: https://www.eventure-online.com/parthen-uploads/154/S SAI/img1_257622_EZXRnwb5I6.jpg


57

POSTERS P-01 Comparison of central venous catheterization techniques in paediatric patients: seldinger vs. modified seldinger technique In-Kyung Song, Ji-Hyun Lee, Hee-Soo Kim, Jin-Tae Kim Seoul National University Hospital, South-Korea Background: Seldinger technique and modified Seldinger technique have been generally used for central venous catheterization. We compared the Seldinger technique with the modified Seldinger technique for ultrasound-guided central venous catheterization in paediatric patients. Methods: In this prospective randomised controlled study, paediatric patients aged between 1 day and 5 years were randomised into 2 groups according to the central venous catheterization technique: the Seldinger and the modified Seldinger technique. Time variables (time to 1st successful puncture of the vein, time to successful insertion of the guide wire, total time to successful central venous catheterization), frequency variables (number of the puncture attempts, number of the guide wire insertion attempts), success rates (1st successful puncture rate, 1st successful guide wire insertion rate), and complications were compared. Results: One hundred thirty-two central venous catheterizations were performed without failure. There were no statistically significant differences in time and frequency variables, success rates, and complications between the Seldinger and the modified Seldinger technique. Time to 1st successful puncture of the vein and number of the puncture attempts were significantly greater in newborns (P = 0.03 and P = 0.02) with the Seldinger technique, whereas with the modified Seldinger technique, number of the puncture attempts was larger in newborns (P = 0.02). Conclusions: In paediatric patients, the modified Seldinger technique showed no superiority over the Seldinger technique concerning accuracy and easiness.

tive PRBC transfusion. 22 (39%) patients required blood transfusion in the postoperative period. Three patients required intraoperative intravenous calcium and one of them required intravenous bicarbonate.46 patients were kept electively intubated after surgery. Major factors for intubation were massive blood loss and long duration of surgery. None of the patients required surgical reintervention or re-intubation of the trachea. Conclusion: The main challenge of nasopharyngeal angiofibroma remains massive blood transfusion. Even with the advent of endoscopy and preoperative embolization, most of these patients require intraoperative transfusion of blood and blood products though massive blood transfusion is rare. Only if the surgery is extensive does the patient require to be kept electively intubated.

P-03 A pediatric difficult airway – anesthetic experience with a Cherubism case

Filipa Baena Mendes Coelho1, Maria Joao Vilaca1, Ana Faısco1, Eduardo Varzim1, Gil Alexandre1, Maria Jose Cabral2 1 Hospital Prof. Dr. Fernando Fonseca, Portugal, 2Hospital Dona Estefania, Portugal Introduction: Cherubism is an autosomal dominant disorder of variable penetrance, with onset in early childhood (typically in the 3–4 years of age). There are approximately 200 reported cases in medical publications., the majority being males. It results from an imbalance between the osteoclastic and osteoblastic activity in the mandible and maxillary bones. The healthy normal bone is replaced with exuberant amounts of fibrous tissue that are responsible for the typical „chubby-cheeked”resemblance to a cherub. Case Report: Nine year old child, scheduled for elective hypospadias, hydrocele and supra-umbilical hernia correction under general anesthesia.

P-02 Perioperative management of juvenile nasopharyngeal angiofibroma (JNA): A retrospective analysis of 56 patients from a single tertiary care institute Jyotsna Punj1, Saurav Gupta2, Aayushi Garg2, Ravindra Pandey2, Vanlal Darlong2, Renu Sinha2, Chandralekha2 1 Department of Anesthesiology, All India Institute of Medical Sciences, India, 2AIIMS, India Introduction: There is paucity of literature in the peri- anesthetic management of Juvenile Nasopharyngeal Angiofibroma (JNA). This retrospective analysis was undertaken to determine the current trends and management of these patients. Methods: Retrospective data of 56 patients operated from 2005– 2013 at a tertiary care hospital were analyzed. Results: Patients were between 8 to 31 years with a median of 16 years. Mean duration of anesthesia and surgery was 165 min (range: 60–540 min) and s 208.4 min (range: 90–600 min) respectively. Pre-operative embolization was done in 23 (41%) patients. Mean blood loss was 1240 ml (range: 50–6000 ml). Blood loss was directly proportional to the higher stage of JNA. Mean blood loss in patients who underwent embolization was 1580.4 ml vs. 1002.4 ml in those who did not. 67% patients required intra-opera-

Fig. 1 Source: https://www.eventure-online.com/parthen-uploads/154/SSAI/ img1_264792_AEfEVN15F5.jpg


58 Previous diagnostics: cherubism and Attention Deficit Hyperactivity Disorder. Previous surgeries: tonsillectomy under general anesthesia at 5 years old. No anesthetic complications. After induction of general anesthesia mask ventilation became very difficult. Help from a second anesthetist was needed and, with a four hand seal, it became possible to maintain adequate ventilation and oxygenation. Oral tracheal intubation was only successful after the third attempt and it was necessary to use a frova intubation stylet. Muscular relaxant was only administered after the correct position of the endotracheal tube was confirmed. The anesthesia was maintained using an air/oxygen mixture and sevoflurane. The total duration of the procedure was 2 h 30 h. Extubation was accomplished in the end of the surgery without any additional complications and the immediate post-operative recovery period, which took place in a pediatric intensive care unit, was free of any adverse event.

P-04 Caesarean section in a parturient with preexisting Transverse myelitis: an anaesthetist’s dilemma Srividhya Jayant Iyer KK women and children’s hospital, Singapore Introduction: Transverse myelitis is an inflammatory, spinal cord disorder causing motor, sensory and autonomic dysfunction. Pregnancy in patients with pre-existing transverse myelitis is extremely uncommon. There are several anaesthetic challenges to consider when these patients present for surgery. These include autonomic dysreflexia, hyperkalemia following use of succinylcholine, poor respiratory reserve and possible diaphragmatic paralysis in patients with high lesions. In addition, there is potential for both general and neuraxial anaesthesia to aggravate symptoms of pre-existing transverse myelitis. Case description: We discuss the management of a 35-year-old Malay primigravida presenting for elective Caesarean section at term pregnancy. She was diagnosed with transverse myelitis 20 years ago, associated with tetraplegia and neurogenic bladder. Cervical spine MRI revealed a high lesion at the C5-C6 interval. She also had a previous history of tracheostomy secondary to prolonged ventilation at time of her diagnosis. Given these considerations and the concern of autonomic dysreflexia, decision was made to proceed with spinal anaesthesia instead of general anaesthesia. Intra-operative course was uneventful with stable hemodynamics and delivery of a healthy newborn. Post-operatively, patient had delayed recovery of both sensory and motor components, taking 30 h to return to baseline levels, but she was subsequently well and discharged home. Discussion: We discuss the merits of neuraxial anaesthesia vs general anaesthesia in this rare group of patients, for who there is limited evidence in literature for management. Treatment should be should be individualised, along with multi-disciplinary approach and careful planning for safe provision of anaesthesia in these mothers.

P-05 Diagnosis of HELLP syndrome. Where are we? Lina Grauslyte1, Asta Zavackiene2, Egle Brukiene2, Vilda Baliuliene3, Andrius Macas2, Kestutis Rimaitis2 1 Lithuanian University of Health Sciences, Lithuania, 2Lithuanian University of Health Sciences–- Kaunas Klinikos, Lithuania, 3Lithuanian University of Health Sciences – Kaunas Clinics, Lithuania Introduction: HELLP syndrome is a rapidly progressing condition which requires distinct diagnostic considerations. The goal of the study was to evaluate the means of diagnosis applied for HELLP syndrome and assess their impact on maternal and neonatal outcomes. Methods: A retrospective observational cohort study was carried out using medical records of tertiary perinatology center with the diagnosis of HELLP syndrome from the period of time between 2005 and 2013. Patients were grouped by Mississippi-Triple-Class system. Means of diagnosis and treatment outcomes were analyzed within those groups. Results: Among the 45 patients with HELLP syndrome included in the study, 58% (n = 26) fit the HELLP syndrome criteria and 42% (n = 19) had partial HELLP syndrome. Within the HELLP syndrome group 30.8% of patients fit Class 1, 53.8% and 15.4% had Class 2 and Class 3 HELLP syndrome respectively. Severe preeclampsia was present in 96.2% of HELLP syndrome and 100% partial HELLP syndrome cases. However the level of blood pressure did not correlate with the severity of patients’ condition (P = 0.656, v2 = 18.835). Treatment was based on the Mississippi protocol. Mean time from admission to delivery was 27.5 (27.5) and 38,6 (65) h in HELLP and partial HELLP group respectively. Maternal complications developed in 4.4% of all cases and in the HELLP group 15.38% of cases ended in perinatal death. Conclusions: HELLP syndrome is a multiorganic disorder whose diagnosis should be based on biochemical laboratory evidence. Vigilance in recognition of HELLP syndrome and appropriate treatment are essential to ensure the better maternal and neonatal outcome.

P-06 Prevalence of infectious complications in patients with severe burns

Bretislav Lipovy1, Hana Rihova1, Pavel Brychta1, Marketa Hanslianova1, Jirı Jarkovsky2, Ivan Suchanek1 1 University Hospital Brno, Czech Republic, 2Masaryk University Brno, Czech Republic Introduction: Today, infectious complications represent a significant medical and economic problem not only in severely burned patients but also in patients that need intensive care in general. Severely burned patients are daily confronted with a number of PPM (potentially pathogenic microorganisms). Methods: In total, the EBA database selected 87 centers both in Western and in Eastern Europe. For the diagnosis of various infectious complications in patients with thermal trauma was used ABA recommendation (American Burn Association). Results: We randomly assigned 134 patients (44 women) from 27 burn centers in Europe. The mean age of the group was 40.39 years (SD 22.17). Average ABSI was 7.5 (SD 2.54), the average size of the burned area was 30.49% TBSA (SD 20.14). Infectious complications were observed in 92 patients (68.7%). A total of 76 patients (56.7%) met the criteria for infection of the burned area, 26 patients (19.4%) for bloodstream infection, 21 patients (15.7%) for pneumonia, 13 patients (9.7%) for infection of the urinary system. 29 patients (21.6%) were found multifocal infection.


59 Gram positive bacteria strain as a potentially pathogenic microorganism was identified in 67 patients (50.0%), Gram-negative bacteria strain in 73 patients (54.5%), and in 18 patients (13.4%) were found yeasts. In none of the patients in the group has been isolated filamentous fungus. Conclusion: In this study we reported very important microbiological results from patients with severe or critical burns in Europe.

P-07 Risk of contrast-induced nephropathy in patients undergoing Aneurysmal coiling treatment Chunghee Joo1, Hyunjoo Jung2 1 Catholic University of Korea, South-Korea, 2Uijeongbu St Mary’s Hospital, South-Korea Introduction: Contrast induced nephropathy (CIN) is a wellknown potential complication of angiography. However, the incidence and the risk factors of CIN were unknown in patients performed cerebral aneurysmal coiling procedures. Methods: Data from Jan. 2011 to Dec.2014 was retrospectively reviewed in patients performed cerebral aneurysmal coiling. CIN was defined as an absolute increase of serum creatinine (≥ 0.5 mg/ dL) or relative increase (≥ 25%) in baseline serum creatinine value at 48–72 h after exposure to a contrast agent. We analyzed the incidence and risk factors of CIN after the use of contrast for cerebral aneurysmal coiling procedure. Results: The cerebral aneurysmal coiling procedures were performed in 194 patients. CIN was developed in 23 patients (23/194, 11.8%). Among 23 episodes of CIN, 18 were categorized as Grade 1 (18/194, 9.3%), 5 were categorized as Grade2 (9/194, 4.6%), none was categorized as Grade 3 (0/194, 0%). Procedure accompanied by craniectomy (P < 0.001) of diagnostic angiography within prior 24 h (P = 0.025), and emergency procedures (P = 0.018) were risk factors of CIN. However, basal GFR, BUN, serum creatinine, hematocrit, use of N-acetylcystein, cumulative dose of N-acetylcystein, duration of operation, amount of administered fluid, amount of administered colloid, urine output, fluid balance during operation, use of inotropics and fluid balance within 24 h were not meaningful. Conclusion: CIN is common in patients with cerebral aneurysmal coiling, and the procedures should be cautiously performed in some patients.

P-08 The effect of sevoflurane versus desflurane on postoperative catheter-related bladder discomfort: a prospective randomised study Hee-Pyoung Park, Hyun-Chang Kim, Young-Jin Lim Seoul National University Hospital, South-Korea Background: Catheter-related bladder discomfort (CRBD) due to an indwelling urinary catheter can cause postoperative distress, and the mechanism underlying CRBD is linked to muscarinic receptor activation. Inhalation of anaesthetic agents such as sevoflurane and desflurane has differential inhibitory effects on muscarinic receptors. In this investigation, we compared the effect of intraoperative sevoflurane versus desflurane inhalation on postoperative CRBD in patients undergoing transurethral bladder tumour excision (TURBT). Methods: A total of 89 patients undergoing TURBT were randomly allocated to two groups: the sevoflurane group (n = 45),

who received sevoflurane for maintenance of general anaesthesia; and the desflurane group (n = 44), who received desflurane. The incidence and severity (mild/moderate/severe) of CRBD were assessed at 0, 1, 6, and 24 h postoperatively. Results: The incidence of CRBD was significantly lower in the sevoflurane group than in the desflurane group at 0 (64 vs. 89%, P = 0.012), 1 (56 vs. 89%, P = 0.001), and 6 h (51 vs. 77%, P = 0.019) postoperatively. The severity of postoperative CRBD and the number of patients treated with tramadol for CRBD were comparable between the two groups. Conclusions: Sevoflurane as a maintenance agent of general anaesthesia decreased the incidence of early postoperative CRBD in patients undergoing TURBT, compared to desflurane.

P-09 Hydroquinone shows neuroprotective potential in experimental ischemic stroke model via attenuation of blood-brain barrier disruption Jun Hwi Cho, Chan Woo Park, Taek Geun Ohk, Myoung Chul Shin, Moo Ho Won Kangwon National University, South-Korea Introduction & Methods: Hydroquinone (HQ), a major benzene metabolite, occurs naturally in various plants and food, and is also manufactured for commercial use. Although many studies have demonstrated the various biological effects of HQ, the neuroprotective effects of HQ following ischemic stroke have not been investigated. Therefore, in this study, we first examined that the neuroprotective effects of HQ against ischemic damage in a focal cerebral ischemia rat model. Results: It was proven that pre- and post-treatment with 100 mg/ kg of HQ protects from ischemia-induced cerebral damage, which was confirmed by evaluation of neurological deficit, PET (Positronemission tomography) and TTC (2,3,5-triphenyltetrazoliumchloride) staining. In addition, pre- and post-treatment with 100 mg/ kg of HQ significantly attenuated ischemia-induced Evans blue dye extravasation, and significantly increased the immunoreactivities and protein levels of SMI-71 and glucose transporter-1 (GLUT1), which were well-known as useful makers of endothelial cell, in ischemic cortex compared to vehicle-treated-group. Conclusion: Briefly, these results indicate that pre- and post-treatment with HQ can protect from ischemic damage induced by transient focal cerebral ischemia, and the neuroprotective effects of HQ may be closely associated with the prevention of BBB disruption via increasing of SMI-71 and GLUT-1 expressions. Keywords: Hydroquinone; ischemic stroke; focal cerebral ischemia; neuroprotective effects; blood-brain barrier

P-10 Pain relief options after craniotomy Juliana Dudko, Gediminas Banevicius, Andrius Macas, Greta Butenaite Lithuanian University of Health Sciences - Kaunas clinics, Lithuania Introduction: Severe postoperative pain impairs the quality of recovery. Our goal was to evaluate severity and treatment of postoperative pain after scalp nerve blockade (B), wound infiltration (I) or systemic analgesia (S) after craniotomy. Methods: This prospective, double-blind, randomized observational study included 120 adult patients (three equal groups) undergoing craniotomy under general anesthesia. Groups B and I received 0.25% bupivacaine +1% lidocaine with 1:20,0000 adrena-


60 line and group S received paracetamol 1 g and ketoprofen 2 mg/ kg intravenous after skin closure. Postoperative pain was assessed at 1, 3, 6 and 24 h using a visual analog scale. Ketorolac, paracetamol and pethidine were administered as rescue analgesia. Time until the first rescue analgesia was recorded. Data were analyzed using Kruskal Wallis, Kaplan Mayer, Chi square tests. Results are presented as mean standard deviation. P < 0.05 was regarded as significant. Results: Main pain scores were significantly lower in group B up to 1 h (B 15 22, Me = 5; I 19 22, Me = 8; S 42 33, Me = 39), P = 0 and 24 h (B 13 20, Me = 8; I 24 26, Me = 15; S 30 31, Me = 21),

P = 0.013. Administered ketorolac doses were significantly lower in group B (B 31 30 mg, Me = 30; S 50 33 mg, Me = 30), P = 0.04. Patients required significantly less doses of paracetamol in group B (B 100 303 mg, Me = 0; S 450 552 mg, Me = 0), P = 0.001. Duration for the requirement of first rescue analgesia was significantly longer in group B (B 548 503 min; I 436 442 min; S 146 134 min), P = 0. Conclusion: Scalp nerve blockade decreases the incidence and severity of postoperative pain and doses of rescue analgesia in craniotomy patients.


[A new postgraduate education program of the German Society of Anaesthesiology and Intensive Care Medicine].

Clinical guidelines on central venous catheterisation. Swedish Society of Anaesthesiology and Intensive Care Medicine.

The 50th Congress of the European Society for Surgical Research. June 10-13, 2015, Liverpool, United Kingdom: Abstract.

Abstracts of the 33rd International Congress of the International Society of Blood Transfusion, in conjunction with the 33rd Congress of the KSBT and the 2014 Congress of the Korean Hematology Societies, May 31-June 5, 2014, Seoul, Korea.

26th annual congress of the European Society of Intensive Care Medicine.

Society of Critical Care Medicine presidential address-44th annual congress, January 2015, Phoenix, Arizona.

French Intensive Care Society, International congress - Réanimation 2016.

Abstracts of the XXV Congress of the International Society on Thrombosis and Haemostasis, June 20-25, 2015.

Erratum to: European Resuscitation Council and European Society of Intensive Care Medicine 2015 guidelines for post-resuscitation care.

[Recommendations of the German Society of Anaesthesiology and Intensive Care Medicine on structured patient handover in the perioperative phase : SBAR concept].

The 33rd World Congress of Internal Medicine: Nusa Dua, Indonesia, August 22-25, 2016.

The development of anaesthesiology in Iceland. A short survey.

Abstracts of the 17(th) International Congress of the Hungarian Society for Microbiology, July 8-10, 2015, Budapest, Hungary.

Abstracts of the 1st Congress of the European Academy of Neurology, Berlin, Germany, June 2015.

17(th) Congress of the European Society for Sexual Medicine.

Proceedings of the 17(th) Annual Congress of the European Society for Sexual Medicine, Copenhagen, Denmark, February 5-7, 2015.

Comparison of Patient Costs in Internal Medicine and Anaesthesiology Intensive Care Units in a Tertiary University Hospital.

European Society of Intensive Care Medicine. Expert panel: the use of the pulmonary artery catheter.

Society of Critical Care Medicine Presidential Address-43rd Annual Congress, January 2014, San Francisco, California.

Common congress swiss society of pediatrics and swiss society of infectiology : forum fribourg, Switzerland, june 20-22, 2002.

Abstracts of the XXIV European Congress of Perinatal Medicine, June 4-7, 2014, Florence, Italy.

XXV Nordic-Baltic Congress of Cardiology. Tallinn, Estonia, June 4-6, 2015: Abstracts.

The Scandinavian Society of Anaesthesiologists, 1950-1975.

Journal of Intensive Care reviewer acknowledgement 2015.