Full text - JICS - The Intensive Care Society

E-supplement 

Research poster presentations 

State of the Art 2011 Meeting 

Each poster has been given a number. This relates to its poster board number. 

Poster no. Page no. Poster no. Page no. 

1. The use of recombinant activated protein C: S-3 

a systematic review ISF 

J Al Shakarchi 

3. Physician’s attitudes towards admitting stroke S-3 

patients to critical care units (CCU) 

H Alshathar, J Beavan 

4. Acute kidney injury in critically ill patients with S-3 

A/H1N1 pneumonitis in 2010/11 ISF 

M Atkinson, S Chukkambotla, A Krige 

7. Vitamin D deficiency is common among patients S-4 

with severe sepsis, correlates with gene expression 

and is associated with survival ISF 

AJ Berlanga-Taylor, J Radhakrishnan, E Davenport, E 

Svoren, P Hutton, SV Ramagopalan, GC Ebers, 

CJ Hinds, JC Knight on behalf of the GAinS Investigators 

8. Relatives’ experiences of confusion and agitation S-4 

in critical care patients 

M Buckel, C Roberts, J Baldwin, S Laha 

11. Comparison of extravascular lung water measured S-4 

using the transpulmonary thermodilution method 

and a chest radiograph score and outcome from 

acute lung injury BTS 

T Craig, L Brown, C Calfee, J Howard, M Matthay, D 

McAuley 

12. Leukocyte-derived Oncostatin M in ALI drives S-5 

S-3 inflammation and protease production and 

inhibits epithelial wound repair BTS 

A Davey, CM O’Kane, ST McKeown, S McFarlane, TR Craig, 

M Shyamsundar, S Brett, J Tonso, DF McAuley 

13. Creatine kinase as a predictor of acute renal S-5 

failure in critical care 

EA Davies, GE Campbell, MD Pugh, M Myers, 

J Baldwin, N Miller-Biot, P Bunting, CH Robertson 

16. Lifting the veil off sedation: towards a more S-6 

wakeful intensive care (ICU) 

K Everingham, T Fawcett, T Walsh 

17. A pilot research study: do raised biomarkers S-6 

predict major complications earlier than clinical 

suspicion following cardio-oesophagectomy ISF 

D Frimpong, K McGrattan, J Ward 

20. The use of an inflammatory biomarker panel S-7 

incorporating the BAL/blood ratio of monocytic 

surface TREM-1 in the diagnosis of ventilatorassociated 

pneumonia ISF 

V Grover, P Kelleher, D Henderson, P Pantelidis, 

F Gotch, N Soni, S Singh 

22. Indications and outcomes for patients with HIV S-7 

admitted to the intensive care unit ISF 

S Haldar, MP Vizcaychipi 

23. New concept using Passive Infra Red (PIR) S-8 

technology for contactless detection of breathing 

movement: a pilot study on 150 adult patients 

V Hers, D Corbugy, I Joslet, P Hermant, 

J Demarteau, G Vandermoten, JP Hermanne 

24. The impact of critical care without walls: S-8 

a prospective service evaluation 

D Horner, S Ingleby, K Anderson, A Grayson, S Jones 

25. AKI in elderly emergency abdominal S-9 

surgery patients 

A Krige, E Baird, J Bannard-Smith, V Meadway 

26. Predicting early readmission to intensive care S-9 

using the Modified Early Warning Score (MEWS) 

R Lloyd, A Kaliappan, N Wee, R Parker 

27. Readmissions to intensive care units in Scotland: S-10 

epidemiology, risk factors and outcomes 

NI Lone, KM Rowan, TS Walsh, SH Wild, GD Murray 

28. Nasal potential difference as a measure of S-10 

respiratory epithelial sodium transport in clinical 


R Mac Sweeney, J Davies, M Parker, B Kelly, S Elborn, 

CS Calfee, MA Matthay, DF McAuley 

32. Deactivated monocytes: not hypo-responsive S-10 

but reprogrammed ISF 

DJP O’Callaghan, KP O’Dea, M Takata, AC Gordon 

33. Citrate based continuous renal replacement S-11 

therapy is associated with significantly longer 

circuit life compared to heparin or epoprostenol 

L Tovey, M Raimundo, S Di Gangi, M Terblanche, 

H Dickie, M Ostermann 

34. Outcomes of patients with HIV and AIDS admitted S-12 

to intensive care units in the United Kingdom — 

analysis of the ICNARC Case Mix Programme BTS 

RJ Parker, GS Power, DA Harrison, KM Rowan 

35. Of mice and men — translational modelling of S-12 


BV Patel, MR Wilson, M Takata 

37. Serial muscle ultrasound detects acute muscle S-13 

loss in multi-organ failure 

ZA Puthucheary, J Rawal, B Connolly, M McPhail, G 

Ratnayake, PS Sidhu, D Shrikrishna, P Hopkins, 

N Hopkinson, M Polkey, MJ Rennie, A Rowlerson, J 

JICS Volume 13, Number 1, January 2012 S-1


Poster no. Page no. Poster no. Page no. 

Moxham, S Harridge, N Hart, H Montgomery 

38. Patterns of gene expression associate with risk S-13 

of death in patients with severe sepsis due to 

community-acquired pneumonia ISF 

J Radhakrishnan, E Svoren, P Ellis, C Langford, 

P Hutton, C Garrard, CJ Hinds, JC Knight, on behalf 

of the GAinS Investigators 

42. Gender differences in inflammation in a model S-14 

of acute lung injury induced by inhaled 

lipopolysaccharide in healthy volunteers BTS 

E O’Brien, M Shyamsundar, CM O’Kane, DF McAuley 

43. Capillary lactate in critical care ISF 

S-14 

D Soo, J Baldwin, N Miller-Biot, E Shardlow, 

E Davies, P Bunting, S Laha 

44. Does the prophylactic use of Octenisan skin S-14 

washes reduce the incidence of bacteraemias 

and MRSA acquisition in critical care ISF 

C Spencer, D Orr, S Hallam, E Tillmans 

45. Regionalisation of ICU and ECMO services in S-15 

the UK; beliefs about the evidence, benefits 

and harm — a national survey 

N Stewart, K Gunning, BH Cuthbertson 

46. Protocols for the prevention of contrast-induced S-15 

nephropathy: a 2011 survey of intensive care units 

in the United Kingdom 

Strachan JM, Crilley T, Parvizi S, DeVile MPJ 

47. Decreased levels in elafin due to proteolytic S-16 

cleavage may contribute to alveolar inflammation 

in the pulmonary compartment in patients with 

ALI BTS 

This poster will now be displayed on Wednesday 

A Kerrin, C O’Kane, M Shyamsundar, T Craig, 

DF McAuley, CC Taggart 

48. An audit of infection characteristics in patients S-16 

with acute liver failure secondary to paracetamol 

overdose ISF 

E Theocharidou, B Agarwal, AK Burroughs, A Walecka 

50. Airflow distribution with manual hyperinflation S-16 

as assessed through gamma camera imaging BTS 

H Van Aswegen, A Van Aswegen, H Du Raan, 

R Du Toit, M Spruyt, R Nel, MED Maleka 

53. Outcomes and APACHE II scores for patients S-17 

with alcoholic liver disease and ICU admission; a 

retrospective observational cohort study 

J Welbourne, K Gunning 

55. Deep vein thrombosis (DVT) in critically ill patients S-17 

R Moroi, M Takeda, T Harada, M Namiki, A Yaguchi 

56. Airway device and quality of cardiopulmonary S-17 

resuscitation 

J Yeung, G Perkins, F Gao 

57. Professional background of team leader and S-18 

quality of CPR 


58. Feedback and prompt devices and quality of S-19 

chest compressions 


Key: 

ISF 

BTS 

— Abstracts relating to the International Sepsis Forum 

— Abstracts relating to the British Thoracic Society 

S-2 

Volume 13, Number 1, January 2012 JICS


1. The use of recombinant activated protein C: 

a systematic review 

J Al Shakarchi 

Good Hope Hospital, Birmingham, UK 

Although recombinant activated protein C has been used in numerous 

intensive care units, its use in septic patients remain controversial. We 

aimed to evaluate whether recombinant activated protein C is effective in 

the treatment of sepsis in adult patients. 

We searched Medline, Embase and DOAJ for randomised control trials 

comparing the additional use of recombinant activated protein C against 

placebo in the treatment of sepsis in adult patients. Strict inclusion criteria 

and thorough appraisal of the reviews was required to ensure comparability 

of the included papers. 

Our dataset comprised of individual data on 4,633 patients from four 

randomised controlled trials that compared the additional use of 

recombinant activated protein C in the treatment of sepsis in adult 

patients. Only one of the papers showed statistically significant 

improvement in survival with the use of recombinant activated protein C. 

The other three studies did not show statistically significant results. 

However the point estimate favoured its use in only one of the three 

remaining studies. 

From the data we have gathered it may be reasonable to conclude that 

the current evidence does not support the use of recombinant activated 

protein C in addition to standard therapy in adult patients with sepsis. 

Therefore until there is more evidence for its use, intensive care units 

should refrain from using this therapy. 

3. Physician’s attitudes towards admitting stroke 

patients to critical care units (CCU) 

H Alshathar*, J Beavan † 

*Tunbridge Wells Hospital, Kent, UK. † Royal Derby Hospital, Derby, UK 

Patients with stroke in the UK are rarely admitted to critical care units. 

Acute stroke treatment has changed with thrombolysis and more medical, 

neurovascular and neurosurgical interventions. These recent changes may 

have led to acute stroke patients accessing more critical care beds. We 

explored physician’s attitudes to such access. 

A web-based questionnaire survey of intensivists, anaesthetists with 

critical care sessions, stroke physicians, neuorologists and geriatricians 

through email and specialty websites of the Intensive Care Society, British 

Association of Stroke Physicians and British Geriatrics Society. 

Respondents were asked to rate four stroke cases (differences in age, 

comorbidity and aetiology/potential intervention of stroke) for the 

likelihood of considering ICU admission as well as requesting comments. 

Two hundred and ten physicians in the UK took part in the survey; 

(122/210 (58%) intensivists/anaesthetists with critical care sessions, 

60/210(29%) stroke physicians, 16/210 (8%) neurologists and 12/2010 

(6%) geriatricians). The majority (132/208 (64%)) were consultants; 

101/207 (49%) worked in district general hospitals, 69/207 (33%) in 

teaching hospitals with or without 37/207 (18%) neurosurgical services. 

Most (170/206 (83%)) had admitted patients with acute stroke to a 

ICU. Overall 160/208 (77%) had been involved with thrombolysis for 

acute stroke, but 55% of anaesthetists. Most had experience of post 

thrombolysis monitoring in a stroke unit hyperacute bay (116/169 

(68.5%)). 

Case one described neurological deterioration in a young person with a 

large stroke where the outcome is uncertain, but may be good if support is 

provided. Stroke physicians (86%) and neurologists (86%) were more 

likely to admit/consider ICU admission than intensivists (60%), 

anaesthetists (62%), and geriatricians (66%). 

Case two described a situation suspicious of basilar artery thrombosis 

requiring urgent medical and neurovascular intervention with poor 

prognosis without intervention. Neurologists (88%) and stroke physicians 

(85%) were much more likely to consider support, than intensivists (33%) 

or anaesthetists (52%). There was no difference in respondents working in 

neurosurgical centres. 

Case three had been recovering well from his stroke and had developed 

a potentially reversible condition (pneumonia). Intensivists (62%) and 

anaesthetists (54%) were more likely to consider admission than stroke 

physicians (41%), neurologists (38%) and geriatricians (33%). 

The fourth case had dementia and large intracranial haemorrhage with 

poor prognostic features. The majority of physicians (96.55%) agreed 

against admission to ICU. 

A third of respondents provided us with comments. Themes raised 

included difficulty in predicting prognosis, communication, the decision 

being in the hands of neurosurgeons, rationing/capacity of ICU beds, 

differing referral patterns depending on the status/geography of the stroke 

service. 

Our survey showed that many physicians involved in stroke and critical 

care are considering critical care support to stroke patients, but decisions 

are affected by service as well as patient factors. Critical care teams need to 

be guided by evidence based advice from stroke teams on patient selection 

for ICU and should be included in planning of stroke services. 

4. Acute kidney injury in critically ill patients with 

A/H1N1 pneumonitis in 2010/11 

M Atkinson*, S Chukkambotla † , A Krige † 

*North Western Deanery, Manchester, UK. † Royal Blackburn Hospital, 

Blackburn, UK 

A/H1N1 infection is a major seasonal cause of illness requiring critical care 

admission. A high proportion of A/H1N1 positive patients develop acute 

kidney injury (AKI). 1 Following the model of a single season, multicentre 

observational study, 1 we retrospectively examined all A/H1N1 positive 

admissions to a district general hospital (DGH) critical care unit for three 

months starting December 2010 for incidence of AKI using the creatinine 

score from the risk, injury, failure, loss of function and end-stage (RIFLE) 

criteria and its associations with mortality, incidence and duration of 

intermittent positive pressure ventilation (IPPV), duration of critical care 

admission and provision of renal replacement therapy (RRT). 

Twenty-seven patients were admitted to the critical unit who tested 

positive for A/H1N1. Fourteen (52%) met RIFLE criteria for AKI. Of these, 

three (11%) met the RIFLE criterion for risk (>150% change in creatinine), 

three (11%) met the criterion for injury (>200% change in creatinine), and 

eight (30%) met the criterion for failure (>300% change in creatinine). 

Nine (33% of all patients, 64% of AKI patients) received RRT. Critical care 

mortality was three out of 14 (21%) in patients with AKI and one out of 13 

(8%) in patients without AKI. This difference was not statistically 

significant. Thirteen out of 20 (65%) ventilated patients developed AKI, 

compared with one out of seven (14%) non-ventilated patients. This 

difference was statistically significant (p=0.0329). Excluding fatalities, the 

duration of IPPV was longer in patients with AKI (median 11 days, range 

0-54 days) than in patients without AKI (median one day, range 0-20 

days). This difference was statistically significant (p


balances in patients with acute lung injuries, as our study examined 

patients a year later than Petillä. 

Reference 

1. Pettilä V, Webb SAR, Bailey M et al. Acute kidney injury in patients with influenza A 

(H1N1) 2009. Intensive Care Med 2011;37:763-67. 

7. Vitamin D deficiency is common among patients 

with severe sepsis, correlates with gene 

expression and is associated with survival 

AJ Berlanga-Taylor*, J Radhakrishnan*, E Davenport*, E Svoren † , 

P Hutton † , SV Ramagopalan § , GC Ebers § , CJ Hinds † , JC Knight* on behalf 

of the GAinS Investigators 

*Wellcome Trust Centre for Human Genetics, University of Oxford, 

Oxford, UK. † Queen Mary University of London, Barts and The London 

School of Medicine and Dentistry, William Harvey Research Institute, UK. 

‡ 

John Radcliffe Hospital, Oxford, UK. § University of Oxford, Oxford, UK. 

Deficiency of vitamin D is common and has been linked to many diseases 

at the epidemiological and molecular levels. 1-2 Vitamin D levels are often 

low in hospitalised patients and deficiency of this vitamin is particularly 

severe among intensive care unit patients. 3-4 We hypothesized that vitamin 

D deficiency might be a contributing factor to all cause mortality in 

patients with severe sepsis. Genome wide gene expression was used to 

identify functional correlates of vitamin D deficiency. 

Clinical data, serum and leukocyte RNA was collected from 144 

patients with severe sepsis due to community acquired pneumonia (n=78) 

or faecal peritonitis (n=66) admitted to intensive care and recruited to the 

Genomic Advances in Sepsis (GAinS) study. Using the first available 

sample on admission to intensive care, the hydroxylated form of vitamin D 

(25(OH)D 3 

) was measured with liquid chromatography mass spectrometry, 

peripheral blood leukocytes were isolated at the bedside using the 

LeukoLock filter system (Ambion) and RNA hybridisation was carried out 

on Illumina Human WG6 V3 arrays. We performed uni- and multi-variate 

analysis of the distribution of 25(OH)D 3 

according to survival and 

correlated serum 25(OH)D 3 

levels to whole genome transcriptome 

measurements. 

Patients had a median age of 64 years, 51% male, 93% Caucasian and 

an overall mortality rate at hospital discharge of 24%. Analysis of serum 

levels of 25(OH)D 3 

showed that 97% of patients were deficient 

(


using the chest radiograph and the transpulmonary thermodilution 

method predict mortality in patients with ALI/ARDS. 

A retrospective longitudinal study of 59 ALI patients was performed. 

Clinical data were collected within 48 hours of ALI diagnosis and once 

daily up to 14 consecutive days. A panel of two clinicians systematically 

scored each chest radiograph for the degree of alveolar oedema. The single 

indicator transpulmonary thermodilution technique (PiCCO Pulsion 

Medical Systems, Munich, Germany) was also used to measured EVLW 

which was indexed to predicted body weight. 

The chest radiograph score had only a modest, positive correlation with 

the EVLWI measurements (r=0.35, p


population. Early diagnosis and intervention may prevent ARF, reducing 

morbidity and mortality. Previous retrospective studies have only used 

confirmed cases of rhabdomyolysis with clinically significant 

concentrations of CK. 3 

This prospective observational pilot study collected data from patients 

aged ≥18 years with arterial or central venous pressure lines in situ. Total 

serum CK was analysed on admission and every two days using Trust 

reference ranges for males (38-173 U/L) and females (26-140 U/L). 

Corresponding creatinine and ARF were recorded. Data was analysed with 

2-tailed t-tests. 

Twenty-four patients were recruited (thirteen [54.2%] males, 20 

[83.3%] postoperative, age 57 [49-65], BMI 26.8 [24.0-30.0], APACHE II 

12.7 [9.5-15.0], length of stay 2.2 [1.2-4.3] days, CK 144.1 [± 95.0] U/L). 

There was a high incidence (37.5%) of elevated CK on admission to the 

unit. Two (8.3%) participants developed ARF during their admission. 

There was no significant difference between groups with and without ARF. 

However, the sample did not allow an adequate range of CK values to 

determine true significance. Serial data in one participant with ARF 

showed an apparent relationship between CK and creatinine (Figure 1). 

Figure 1. Example of serial CK (dashed line) and creatinine (solid line) in 

patient with ARF. 

Further work is indicated with a larger sample and the collection of 

additional data such as mortality. More serial data will be helpful in 

determining the predictive value of CK in acute renal failure. 

Acknowledgements: This project was funded by Lancashire Teaching 

Hospitals NHS Foundation Trust. 

References 

1. Reha WC, Mangano FA, Zehman RK, Pahira JJ. Rhabdomyolysis: Need for high index 

of suspicion. Urology 1989;35:292-96. 

2. Huerta-Alardin AL, Varon J, Marik PE. Bench-to-bedside review: Rhabdomyolysis – an 

overview for clinicians. Crit Care 2005;9:158-69. 

3. de Meijer AR, Fikkers BG, Keijzer MH et al. Serum creatine kinase as a predictor of 

clinical course in rhabdomyolysis: a 5-year intensive care survey. Intens Care Med 

2003;29:1121-25. 

16. Lifting the veil off sedation: towards a more 

wakeful intensive care (ICU) 

K Everingham, T Fawcett, T Walsh 

University of Edinburgh, Edinburgh, Scotland 

Strategies to reduce sedation are associated with improved patient 

outcomes during critical illness. 1 The implementation of daily sedation 

reviews and sedation holds is frequently challenging, despite inclusion in 

National Patient Safety Programmes. 2 Sedation management is 

predominantly a nurse-led activity, but few studies have specifically 

explored critical care nurses experiences and feelings surrounding sedation 

management and the clinical decisions they make. These issues are key to 

successful implementation of systematic changes in care. 

We aimed to provide insight into beliefs surrounding sedation 

practices, especially sedation ‘holds’, among ICU nurses focusing on how 

the environment, nursing behaviours, knowledge and personal experiences 

S-6 

influence their clinical decisions. 

Sixteen qualitative interviews were completed employing a 

phenomenological approach whereby an individual’s lived experience of 

their world is explored to gain a deeper understanding, interpretation and 

meaning of phenomena. Nurses of varying ages, gender and nursing 

experience were interviewed at the bedside. Taped interviews were 

transcribed, repeatedly listened to and supported by field notes. Non-verbal 

gestures and intonations were incorporated. Using an interpretive analysis, 

commonality of themes and meanings were exposed and the contextual 

implications of the findings explored. 

Themes emerged from the data that demonstrate that the lived 

experience of the critical care nurses can militate against optimal sedation 

interventions and patient outcomes. The nurses’ perceived a more wakeful 

ICU population to increase their workload without increased support. A 

pressure of obligation from medical staff to perform sedation holds 

emerged, even if it conflicted with their own professional judgement. There 

was a perception that sedation holds were ‘expected of them’. Related to 

this, traditional power relations between nurses and doctors were still 

evident, wherein the nurses felt they were being perceived as ‘lazy or 

‘wanting an easy shift’ if they opposed sedation holds. These feelings 

manifested as a loss of autonomy and feelings of detachment around the 

process of sedation assessment and management. “Negative” consequences 

of reduced sedation, especially agitation, were strongly associated with less 

sedation. Agitation was elicited as a source of fear, both for nurse’s safety 

and patient safety. Nurses recalled instances where adverse events, such as 

unintentional tube and line removal, occurred as a result of agitation. 

Nurses grappled with feelings of guilt, blame and failure to protect their 

patients from harm, which developed into resentment and apprehension 

in regards to future sedation holds. Each of these feelings impinged 

upon the clinical decisions made and constituted barriers to optimal 

sedation management. 

Despite the evidence demonstrating that less sedation equates to better 

patient outcomes, and although nurses are ideally placed to drive a change 

of practice, there are clear identified barriers that impede them delivering 

optimal sedation care. 

References 

1. Kress J, Pohlman A, O’Connor M et al. Daily interruption of sedative infusions in 

critically ill patients undergoing mechanical ventilation. N Engl J Med 2000;342:1471-77. 

2. NHS Scotland (2009) Scottish Patient Safety Alliance [online] Available from: 

http://www.patientsafetyalliance.scot.nhs.uk/programme [accessed 2nd July 2011]. 

17. A pilot research study: do raised biomarkers 

predict major complications earlier than clinical 

suspicion following cardio-oesophagectomy 

D Frimpong*, K McGrattan † , J Ward † 

*University of Manchester, Manchester, UK. † Lancashire Teaching 

Hospitals NHS Foundation Trust, Preston, UK 

Oesophageal cancer is a common cancer that affects 7500 people per year 

in the UK. 1 Radical treatment can involve surgery (cardiooesophagectomy). 

2 Cardio-oesophagetomy is associated with major 

complications. The main objective of the study is to determine if 

inflammatory markers, released in response to surgery, infection and 

inflammation, can predict complications before clinical suspicion. Earlier 

detection of complications can potentially avoid further invasive 

investigations and reduce morbidity and mortality. 

Nine participants completed the study over an eight-week period. Each 

participant had ten samples; two preoperative samples to determine a 

baseline and eight postoperative samples starting 48 hours postoperatively. 

Participant hospital notes were used to collect information on 

complications. 

In general there was a rise in the inflammatory markers postoperatively 

followed by a rapid decline. Eight of the nine patients developed 

complications; 55% of the participants had arrhythmias in the first four 

postoperative days. One patient had an anastomotic leak and a 

bronchopleural fistula. CRP remained elevated in this patient and PCT 



showed a secondary rise. Rises in CRP, PCT and neutrophils correlated 

well with complications however did not precede clinical suspicion. 

Inflammatory markers are raised following cardio-oesophagectomy, 

peaking in the first two to three days and declining rapidly. Although some 

correlated with complications none consistently preceded clinical 

suspicion. This study is limited by population size and a large multi centre 

trial is recommended. 

References 

1. Cancer Research UK. Oesophageal Cancer – UK incidence statistics. [Online]. Updated 17 

December 2010. Accessed 01/07/11. Available from: http://info.cancerresearchuk.org/ 

cancerstats/types/oesophagus/incidence/ 

2. Lancashire and South Cumbria Cancer Network. UGI Specialist MDT Operational 

Policy. June 2011. 

20. The use of an inflammatory biomarker panel 

incorporating the BAL/blood ratio of monocytic 

surface TREM-1 in the diagnosis of ventilatorassociated 

pneumonia 

V Grover* † , P Kelleher †‡ , D Henderson †‡ , P Pantelidis †‡ , F Gotch † , N Soni*, 

S Singh* 

*Chelsea and Westminster NHS Foundation Trust, London, UK. † Imperial 

College London, UK. ‡ Imperial College Healthcare NHS Trust, London, 

UK 

Diagnosis of ventilator-associated pneumonia (VAP) is slow and fraught 

with difficulty. Biomarkers may speed up diagnosis. The Triggering 

Receptor Expressed on Myeloid Cells-1 (TREM-1) is elevated in 

extracellular infections 1 and is a putative biomarker. It exists as a surface 

protein on monocytes and neutrophils, together with a soluble isoform. 

The diagnostic utility of bronchoalveolar lavage (BAL) soluble TREM-1 is 

controversial. No data exists on BAL surface TREM-1 in VAP. We 

investigated whether BAL surface TREM-1 expression increases in VAP and 

whether the BAL/blood ratio improves diagnostic accuracy. We also aimed 

to identify a diagnostic biomarker panel given that a single analyte is 

unlikely to classify all VAP cases. 

Ninety-one adults were recruited into four groups and paired BAL and 

blood obtained: 27 with VAP (diagnosed by Clinical Pulmonary Infection 

Score and positive semi-quantitative microbiology), 18 ventilated without 

infection (ventilated control, VC), 15 ventilated with non-pulmonary 

infection (ventilated sepsis elsewhere, VSE) and 27 non-ventilated noninfected 

patients with chronic lung disease (non-ventilated control, NVC). 

Soluble biomarkers (IL-1β, IL-6, IL-8, soluble TREM-1 and procalcitonin) 

and surface markers (monocytic and neutrophilic surface TREM-1, CD11b 

and CD62L) were assayed in each sample, together with peripheral white 

cell count and CRP. Receiver-operator characteristic (ROC) curves were 

constructed for each marker. Data was assessed using the Kruskal-Wallis 

and Mann-Whitney tests, with Dunn’s post-hoc analysis for multiple 

comparisons. The VAP group was compared to VC and VSE groups 

individually. As no significant difference existed, VC and VSE groups were 

combined into a non-VAP group. Fisher discriminant analysis was used to 

construct a diagnostic biomarker panel. 2 

Monocytic surface TREM-1 (mTREM-1) had an area under ROC 

curve (AUC) of 0.89 for diagnosing VAP, improving to 0.94 with the 

mTREM-1 BAL/blood ratio. Other individual markers had AUCs of 

0.56-0.80. A six-marker panel incorporating the BAL/blood ratio of 

mTREM-1 and monocytic CD11b (mCD11b), BAL soluble TREM-1 and 

IL-1β, blood IL-6 and CRP differentiated VAP, non-VAP and NVC groups. 

For VAP, the AUC (95% CI) of this panel was 0.98 (0.96-1.00). 

Sensitivity, specificity and likelihood ratio (LR) were 95%, 93% and 12.9. 

Cross-validation and use of training and validation cohorts confirmed the 

robustness of the panel. 

In conclusion, the BAL/blood ratio of surface mTREM-1 may be useful 

in VAP diagnosis and differentiation from non-pulmonary sepsis. A 

diagnostic biomarker panel incorporating the BAL/blood ratio of mTREM- 

1 and mCD11b, BAL soluble TREM-1 and IL-1b, blood IL-6 and CRP has 

clinical utility in identifying VAP. 

Figure 1. mTREM-1 expression in BAL and the BAL/blood ratio. Box-whisker 

(Tukey) plots of the BAL mTREM-1 levels and the BAL/blood ratio in VAP, 

ventilated control (VC), ventilated sepsis elsewhere (VSE) and non-ventilated 

control (NVC) patients. Medians and inter-quartile ranges are indicated. 

p


Patient demographics and HIV risk factors (n=90) 

Age (mean, SD) 49 (10.9) 

Male Sex (%, n) 83 (75/90) 

Black ethnicity (%, n) 29 (26/90) 

Country of origin UK (%, n) 53 (48/90) 

Africa (%, n) 20 (18/90) 

Other (%, n) 27 (24/90) 

HIV risk group Heterosexual (%, n) 36 (31/85) 

Homosexual (%, n) 58 (49/85) 

IVDU (%, n) 6 (5/85) 

HepBSAg+ (%, n) 12 (7/59) 

HepCAb+ (%, n) 10 (6/58) 

CD4 cell count at time of ICU admission (median, IQR) 168 (30.5, 351) 

History of AIDS defining illness (%, n) 56 (47/84) 

First AIDS defining illness in ICU (%, n) 25 (18/72) 

New diagnosis of HIV in ICU (%, n) 19 (17/90) 

Criteria for HAART met at admission CD4


significant additional critical care workload. With increasing trust wide 

adoption, corresponding education and safety initiatives, a trend towards 

reduction has been seen in duration of stay and cumulative mortality for 

all unplanned admissions. 

References 

1. Kumar A, Roberts D, Wood KE et al. Duration of hypotension before initiation of 

effective antimicrobial therapy is the critical determinant of survival in human septic 

shock. Crit Care Med 2006;34:1589-96. 

2. McQuillan P, Pilkington S, Allan A. Confidential enquiry into the quality of care before 

intensive care unit admission. Br Med J 1998;316:1853-58. 

3. Subbe CP, Davies RG, Williams E et al. Effect of introducing the modified early warning 

score on clinical outcomes, cardiopulmonary arrests and intensive care utilisation in 

acute medical admissions. Anaesthesia 2003;58:797-802. 

25. AKI in elderly emergency abdominal surgery 

patients 

A Krige, E Baird, J Bannard-Smith, V Meadway 

Royal Blackburn Hospital, Blackburn, UK 

Acute kidney injury (AKI) occurs in 1% of all non cardiac surgical patients 

and is associated with higher morbidity and mortality. 1 Development of 

new acute renal failure still carries a morality of up to 50%. The impact of 

AKI on the health economy is significant, with renal replacement therapy 

costing approximately £850/day. 2 Optimising renal blood flow and oxygen 

delivery peri-operatively, aggressively managing severe sepsis, and avoiding 

nephrotoxic drugs may reduce the incidence. The recent NCEPOD report 

highlights continued failure to provide the above and report an incidence 

of 36.6% in the elderly undergoing emergency surgery. 

We undertook a retrospective case note review of patients over the age 

of 65, undergoing emergency, non-vascular, abdominal surgery in a district 

general hospital. Using the ORMIST theatre computer system, 149 patients 

were identified between Nov 2007 and March 2009. Ninety-five sets of 

notes were available of which 27 were incorrectly coded and two were 

unacceptable due to excessive data omission. The remaining 66 case notes 

were systematically reviewed and additional information retrieved from the 

ICE blood results system and ORMIST. Data is reported as mean (SD) or 

median (IQR). The Chi-squared test was used to compare mortality 

between RIFLE classes 2 and the Kruskall-Wallis tests for LOS between 

RIFLE classes. 3 

The mean age of the 66 patients analysed was 78.24 years, 53% were 

female and 47% were admitted to critical care post-operatively. The overall 

incidence of AKI was 36.4% in this high-risk population. Twenty-four 

(38.7%) of 62 cases adequately documented had abdominal sepsis. This 

group had 33% unadjusted mortality in comparison with 13% mortality in 

the group without abdominal sepsis. Table 1 summarises all other results. 

RIFLE Classes 0 Risk Injury Failure 

n 42 12 7 5 

Age (years)* 79.45 (6.3) 77.42 (8.4) 77.14 (5.52) 72.6 (7.89) 

pPOSSUM (%)* 20.22 (22.11) 15.5 (17.36) 46.57 (45) 44.4 (28.33) 

Time to source 64.5 (20.75- 55 (33.75-90) 8 (5-35) 12 (10.5-104.5) 

control (mins) κ 182.75) 

Pre-op IV fluid 2829 (1450) 3091 (1868) 1917 (801) 4600 (2632) 

volume (mL)* 

Hospital LOS (days) κ 18 (12.75-35.5) 20.5 (10.25 14 (5-25) 32 (18.5-34.5) 

-39.5) 

Hospital survival (%)* Δ 88 (32.8) 75 (45.2) 43 (53.5) 80 (44.7) 

* mean (SD); κ median (IQR); Δ p=0.045 

Table 1. Process and outcome data according to RIFLE categories. 

The incidence of AKI in our dataset mirrors the recent NCEPOD 

report 4 and the difference in mortality between RIFLE groups reaches 

statistical significance (see Table 1) with a stepwise increase in mortality 

moving through RIFLE categories until we see a contradictory reduction in 

mortality in RIFLE F. However there are only five patients in this group. 

There may also be selection bias, ie three patients in RIFLE F received RTT, 

indicating they were an elderly group whose baseline function was 

sufficient to provide aggressive multi-organ support where treatment 

limitations may have been deemed more appropriate in other patients. In 

keeping with NCEPOD 4 our series also shows lengthy delays to source 

control and frequently inadequate fluid management. 

References 

1. Brienza N, Gigilio M, Marucci M et al. Preventing kidney injury after non cardiac 

surgery. Current Opin Crit Care 2010;16:353-58. 

2. NHS Blood and Transplant: Organ Donation. http://www.organdonation.nhs.uk 

3. Acute Dialysis Quality Initiative. http://www.adqi.net 

4. NCEPOD – An age old problem. 2011. 

26. Predicting early readmission to intensive care 

using the Modified Early Warning Score (MEWS) 

R Lloyd*, A Kaliappan † , N Wee*, R Parker ‡ 

*Ipswich Hospital, Ipswich, UK. † Addenbrooke’s Hospital, Cambridge, 

UK. ‡ University of Cambridge, UK 

The Modified Early Warning Score (MEWS) is a physiological scoring 

system based on simple observations of a patient’s vital signs. It is widely 

used across the UK by critical care outreach and ward nursing teams as a 

track and trigger score to alert medical teams to a deteriorating patient and 

to escalate levels of care. Higher scores have been associated with increased 

risk of death, ICU admission and cardiac arrests. 1 The usefulness of MEWS 

within Critical Care setting has not been adequately studied. It is not 

common practice to calculate the MEWS when planning to discharge a 

patient back to the ward after their ICU stay. 

After gaining local research ethics committee approval, we investigated 

the association of the MEWS score calculated at the point of discharge 

from intensive Care Unit (ICU) and readmission to ICU within 48 hours. 

We retrospectively analysed all the ward discharges from our ICU for the 

year 2009 (n=532) and calculated their MEWS score before ICU discharge. 

Out of a total 673 admissions, we excluded the 88 patients who died in 

the ICU, 34 who died on the ward following ICU discharge and 19 patients 

who were transferred to other ICUs. The remaining admissions (n=532) 

were included in the analysis. There were 50 readmissions in total. Of 

these 10 were early readmissions within 48 hours. MEWS at discharge 

ranged between 0 to 10 with 1 and 2 being the most frequent score. 

A logistic regression model was used with early readmissions as the 

outcome variable and MEWS as the explanatory variable. After using 

Generalised Estimating Equations to adjust for clustering, we found a 

statistically significant relationship between MEWS and early readmissions 

with an odds ratio for MEWS 1.35(95% confidence interval 1.07-1.69) and 

a robust Z score 2.58. 

MEWS odds 95% CI of Robust Z 

ratio odds ratio score 

MEWS 1.35 1.07-1.69 2.58 

Adjusted for age and gender 1.35 1.07-1.70 2.52 

Adjusted for risk of death (ROD) score 1.41 1.11-1.81 2.76 

Adjusted for BMI (log10 transformed) 1.49 1.17-1.90 3.18 

A group of patients with MEWS score one unit higher than another 

group of patients, are expected to have odds of early readmission 1.35 

times higher on average (95% CI 1.07 to 1.69) than for the other group of 

patients. MEWS was still found to be a significant predictor of early 

readmission even after separately adjusting for age and gender, ROD score 

and BMI. This study shows that it may be beneficial to use the MEWS 

when planning to discharge an ICU patient to the ward. Further studies are 

needed to evaluate if there is a threshold MEWS score above which early 

readmission is more likely. 

Reference 

1. Cullinane M, Findlay G, Hargraves C, Lucas S. An Acute Problem National Confidential 

Enquiry into Patient Outcome and Death. 11th May 2005. www.ncepod.org.uk/2005report 

(accessed 1/07/2011). 



27. Readmissions to intensive care units in Scotland: 

epidemiology, risk factors and outcomes 

NI Lone*, KM Rowan † , TS Walsh*, SH Wild*, GD Murray* 

*University of Edinburgh. † Intensive Care National Audit and Research 

Centre (ICNARC), London, UK 

Readmission to intensive care is associated with poorer outcomes and 

increased resource use. Early readmission is used as an indicator of quality 

of care. Studies investigating patients readmitted to intensive care have 

been limited to using only ICU audit databases to determine risk factors 

and outcomes. In Scotland, there is the unique opportunity to link the ICU 

database to other national healthcare databases. Our aim was to use data 

linkage to assess the validity of records coded as readmissions in the ICU 

database, and to identify risk factors for and report outcomes of patients 

readmitted to all ICUs in Scotland in 2005. 

We used a retrospective cohort design. The national database of ICU 

admissions, SICSAG (Scottish Intensive Care Society Audit Group), was 

linked to the Scottish acute hospital discharges and death registry 

databases. The cohort comprised patients >16 years old admitted to a 

Scottish ICU in 2005. We excluded those who were not at risk of future 

ICU readmission i.e. those dying during their first admission and those 

discharged after 31/12/2005. We used binary logistic regression to identify 

risk factors for readmission and to adjust outcomes for important 

confounders. The outcome was three year mortality after ICU discharge. 

Validity of the readmission field was checked against the linked 

hospital dataset using patients whose hospital admission started and ended 

during 2005. 

There were 8992 ICU admission episodes in the SICASG database in 

2005 of which 6554 had a valid linkage and fulfilled inclusion criteria. 

There were 5894 (89.9%) first admissions; 660 (10.1%) readmission 

episodes and 566 (9.6%) patients had at least one readmission during the 

12-month study period (range 0-9). One quarter of patients (n=148) had 

their first readmission within 48 hours of ICU discharge. In multivariable 

analysis, only out-of-hours discharge (OR1.4, p=0.02), prior 

cardiopulmonary resuscitation (OR0.5, p=0.03), discharge destination 

(p=0.003) and Charlson comorbidity (p=0.001) were independent risk 

factors for readmission. Patients with at least one readmission during the 

12-month study period were significantly more likely to die at three years 

post-ICU discharge than those with no readmissions (mortality 54.1% vs 

30.7%, logrank-χ2 175.6, p


including soluble (sol)-TNF and the adhesion molecule L-selectin. We 

sought to determine whether TACE activity and substrate shedding in 

critically ill patients would be altered when compared to healthy controls. 

Blood samples (day 0, 2, 4 and 6) were taken from mechanically 

ventilated patients (n=5) who had the systemic inflammatory response 

syndrome (SIRS). Purified blood monocytes were obtained by magnetic 

CD14 positive bead selection from peripheral blood mononuclear cells 

(PBMCs). Monocytes were washed and exposed to a LPS stimulus (1µg/mL 

for 60 minutes) before having their TACE activity quantified using a cellbased 

fluorometric catalytic activity assay. 3,4 Monocyte expression levels of 

HLA-DR and of pre and post-LPS TACE and L-selectin were determined 

via flow cytometry. PBMC’s were also placed in 16-hour LPS culture and 

had sol-TNF production quantified by ELISA. 

Funding sources: Both Dr O’Callaghan and Dr Gordon have received 

research support from the Intensive Care Foundation. Dr Gordon is in 

receipt of an NIHR Clinician Scientist Fellowship award and is grateful for 

funding through the NIHR-BRC funding scheme. 

References 

1. Volk H, Reinke, P, Krausch D et al. Monocyte deactivation-rationale for a new 

therapeutic strategy in sepsis. Intensive Care Med 1996;22:S474-81. 

2. Black R, Rauch C, Kozlosky C et al. A metalloproteinase disintegrin that releases 

tumour-necrosis factor-alpha from cells. Nature 1997;385:729-33. 

3. Alvarez-Iglesias A, Wayne G, O’Dea KP et al. Continuous real-time measurement of 

tumour necrosis factor-α converting enzyme activity on live cells. Lab Invest 

2005;85:1440-48. 

4. Scott A, O’Dea KP, O’Callaghan D et al. Reactive oxygen species and p38 MAPK mediate 

TNF-alpha converting enzyme (TACE/ADAM17) activation in primary human 

monocytes. J Biol Chem 2011: Epub 26/08/2011. 

33. Citrate based continuous renal replacement 

therapy is associated with significantly longer 

circuit life compared to heparin or epoprostenol 

L Tovey, M Raimundo, S Di Gangi, M Terblanche, H Dickie, M Ostermann 

Guy’s and St Thomas’ Hospital, London, UK 

Figure 1a and 1b. TACE activity changes over sampling time course (mean + 

SD), n=3-5. (a): Baseline (un-stimulated) activity levels. (b) Activity increase 

from baseline (%) on LPS exposure. * p


34. Outcomes of patients with HIV and AIDS 

admitted to intensive care units in the United 

Kingdom — analysis of the ICNARC Case Mix 

Programme 

RJ Parker*, GS Power † , DA Harrison † , KM Rowan † 

*Aintree University Hospitals NHS Foundation Trust, Liverpool, UK. † Intensive 

Care National Audit and Research Centre (ICNARC), London, UK 

Intensive care unit (ICU) outcome due to human immunodeficiency virus 

infection (HIV) and the acquired immunodeficiency syndrome (AIDS) was 

initially extremely poor. Subsequent data suggest it is now similar to that of 

other general medical patients on ICU. 1 Whether due to better ICU 

management or the availability in developed countries of highly active 

antiretroviral therapy remains debated. 1 

The ICNARC Case Mix Programme (CMP) is the national clinical audit 

of adult critical care units in England, Wales and Northern Ireland. 

Following extensive validation, data are pooled into the CMP Database. 

Since 2006, whether an admission has HIV or AIDS has been collected as 

part of the CMP dataset. 

Of 304,435 admissions to 200 critical care units between 1 April 2006 

and 31 December 2010 893 patients with HIV and 152 with AIDS were 

identified (


References 

1. Ware LB, Matthay MA. The acute respiratory distress syndrome. N Engl J Med 

2000;342:1334-49. 

2. Matute-Bello G, Downey G, Moore BB et al. An Official American Thoracic Society 

Workshop Report: features and measurements of experimental acute lung injury in 

snimals. Am J Respir Cell Mol Biol 2011; 44:725-38. 

3. Ware LB. Modeling human lung disease in animals. Am J Physiol Lung Cell Mol Physiol 

2008;294:L149-50. 

4. Matute-Bello G, Frevert CW, Martin TR. Animal models of acute lung injury. Am J 

Physiol Lung Cell Mol Physiol 2009;295:L379-99. 

37. Serial muscle ultrasound detects acute muscle 

loss in multi-organ failure 

ZA Puthucheary* § , J Rawal*, B Connolly † , M McPhail ‡ , G Ratnayake † , 

PS Sidhu § , D Shrikrishna ∞ , P Hopkins § , N Hopkinson ∞ , M Polkey ∞ , MJ 

Rennie # , A Rowlerson § , J Moxham § , S Harridge § , N Hart † , H Montgomery* 

*University College London, Whittington Hospital NHS Trust, London, 

UK. † Guy’s and St Thomas’ and King’s College London, NIHR 

Comprehensive Biomedical Research Centre, St Thomas’ Hospital, 

London, UK. ‡ Imperial College London, Hammersmith Hospital NHS 

Trust, UK. § King’s College London, UK. ∞ Royal Brompton Hospital, 

Imperial College London, UK. # University of Nottingham, UK. 

Muscle wasting and weakness is a debilitating consequence of critical 

illness. However, tests for the early identification and tracking of muscle 

loss are lacking. Manual muscle testing is currently advocated, but requires 

patient co-operation, which is difficult in the early stages of critical illness. 

Muscle ultrasound is potentially a useful clinical tool as it not only 

provides an objective measure but is also inexpensive and portable. We 

hypothesised that serial muscle ultrasound would be able to identify and 

track muscle loss. 

Critically ill patients were recruited from a district general hospital and 

a university teaching hospital within the first 24 hours of admission. 

Inclusion criteria were (i) likely to remain intubated ≥48 hours (ii) likely 

to remain in critical care ≥7 days. Patients were excluded if they i) were 

pregnant ii) had disseminated malignancy iii) suffered from a primary 

neuromuscular disease. Serial measurements of rectus femoris cross 

sectional area (RF CSA 

) were taken using B-mode ultrasound, on days 1, 3, 7 

and 10 of admission. Bedside physiological data was collected, allowing 

patients to be stratified by numbers of failed organ systems. The primary 

endpoint was a change of 15% of RF CSA 

in 10 days. 

Twenty-six patients were recruited and fulfilled entry criteria at 10 days. 

Using the Sequential Organ Failure Assessment (SOFA) score, six patients 

had single organ failure, and 20 had ≥2 organ failure. Patients with ≥2 had 

significantly greater loss of muscle at 10 days than those with single organ 

failure (19.4±1.94% vs 1.79±1.75%, p=0.003) as shown in Figure 1. Subgroup 

analysis comparing 2-3 organ failure to 4-6 organ failure 

demonstrated no significant difference in muscle loss (-18.1%±5.3 vs 

-20.9%±11.7, p=0.355). No difference was seen in age (52.4±17.6 vs 

54.4±20.8) or Medical Research Council sum scores at day 10 between 

groups (47±17.8 vs 51±9.8, p=0.57). 

Figure 1. Time course of acute muscle loss during ICU stay: single organ vs 

multi-organ failure. 

RF CSA 

is a clinically useful tool for monitoring muscle loss in critically 

ill patients. Substantial muscle loss occurs in patients with ≥2 organ failure 

within the first few days with 19% loss in RF CSA 

by day 10. No change in 

RFCSA was observed in patients with single organ failure. The lack of 

difference in MRC sum score between the groups could indicate that the 

contractile properties of the muscle are maintained despite the loss of 

cross-sectional area. 

38. Patterns of gene expression associate with risk of 

death in patients with severe sepsis due to 

community-acquired pneumonia 

J Radhakrishnan*, E Svoren § , P Ellis † , C Langford † , P Hutton ‡ , C Garrard ‡ , 

CJ Hinds § , JC Knight∗, on behalf of the GAinS Investigators 

*University of Oxford, UK. † University of Cambridge, UK. ‡ John Radcliffe 

Hospital, Oxford, UK. § Barts and the London School of Medicine, Queen 

Mary University, London, UK 

Despite advances in supportive management, mortality rates in patients 

with severe sepsis remain high. The mechanisms underlying the 

pathogenesis of sepsis and in particular the basis of adverse outcomes are 

incompletely understood. There is evidence that genetic factors are 

important and may influence sepsis susceptibility and outcome. 

After ethics approval and gaining informed consent, 74 adult patients 

admitted to intensive care with severe sepsis due to community-acquired 

pneumonia (CAP) were recruited. Pregnant patients and those with preexisting 

immune compromise were excluded. Peripheral blood leukocyte 

samples (n=129) were collected at the bedside using a leukodepletion filter 

system (LeukoLOCK, Ambion) on days 1, 3 and 5 following admission to 

the intensive care unit (ICU). Genome wide gene expression was measured 

by hybridising the extracted RNA to whole genome bead arrays (Illumina 

HT12 v4) that interrogate ~48,000 unique transcripts. The findings were 

validated in an additional 55 samples from 30 patients using Illumina 

WGA v3 bead arrays. 

After normalisation, exploratory analysis was performed by hierarchical 

clustering of the principal components contributing to the observed 

variance. Differences between groups of interest were examined using 

Bayesian analysis by fitting hierarchical mixed models with Markov Chain 

Monte Carlo sampling using a Gibbs sampler. Gene set enrichment 

analysis and the DAVID functional gene annotation system were used to 

cluster significant genes into biologically informative pathways. All results 

were confirmed in the validation data set. 

The overall mortality was 17.6% (n=13). The median age was 60 

(IQR=20) years in survivors (S) and 64 (IQR=28) in non-survivors (NS) (p 

>0.05). NS showed significantly higher relative neutrophil counts (87.5 vs 

82.1), lower monocyte counts (4.5 vs 7.6), and a worse oxygenation index 

(14.9 vs 20.6). There were no other significant differences between S and 

NS in terms of demographics, microbiology, organ failures or severity 

scores. 

Exploratory factor analysis by unsupervised clustering revealed a 

previously unidentified substructure in the global gene expression data set 

for the 74 patients. Three distinct clusters of differentially expressed genes 

were defined which displayed a graded increase in mortality rates (5%, 

10%, 33% respectively for each cluster group). Analysis of the validation 

data set using genes defining the clusters in the training set (~2800) 

showed an identical substructure with the same proportional differences in 

mortality rates. Clustering was explained by differences in the expression 

of genes associated with mitochondrial ribosomes, mitochondrial 

membrane associated proteins, and vesicle processing in association with 

class II MHC genes. Poor outcome was also associated with changes in 

glucose metabolism and DNA repair mechanisms related to oxidative 

damage. Significant sex-specific effects on gene expression were noted. 

We have shown how analysis of gene expression can resolve a clinically 

homogeneous cohort of patients with severe sepsis into distinct clusters 

predictive of risk of death. Differential expression of genes associated with 

mitochondrial function made an important contribution to the clustering. 

These findings highlight some convincing mechanistic explanations for 

adverse outcomes in sepsis and could potentially be used to stratify 

patients according to risk of death on admission to ICU. 



Acknowledgements: Dr Radhakrishnan was in receipt of a Wellcome 

Trust Training Fellowship. The study was also supported by funding from 

the Intensive Care Society, the UKCRN, the Sainsbury Family Trusts and 

Sirius Genomics. 

42. Gender differences in inflammation in a model of 

acute lung injury induced by inhaled 

lipopolysaccharide in healthy volunteers 

E O’Brien, M Shyamsundar, CM O’Kane, DF McAuley 

Queens University of Belfast, UK 

Conflicting findings on the effect of gender difference on outcome in 

patients with sepsis and ALI have been reported in observational studies. 

However in patients exposed to infection, females are less likely to progress 

to severe sepsis. The objective of this study was to assess the effect of 

gender on the inflammatory response in a model of ALI induced by 

inhaled lipopolysaccharide (LPS). 

Thirty healthy volunteers from the placebo arms of two clinical trials 

(ISRCTN21056528 and ISRCTN98813895) were included in this study. 

Subjects inhaled 50µg LPS and bronchoalveolar lavage (BAL) was 

performed at six hours after LPS inhalation. Cytokines were measured by 

using cytometric bead array (R&D Systems). Total white cell count 

(WCC) was determined using a haemocytometer. Data are mean [±SD] or 

median [IQR]. 

Figure 1. 

Fourteen (47%) of the volunteers were male. BAL IL-8 (pg/mL) was 

significantly higher in females (Figure 1). There was no difference in BAL 

TNF α, IL-1β, IL-6, MCP-1 and IL-1ra. BAL IL-10 levels were below the 

limit of detection. There was no difference in BAL WCC or neutrophils. 

We have shown that in a model of ALI induced by inhaled LPS, female 

subjects mounted a higher cytokine response as evidenced by a higher BAL 

IL-8 level. The increase in BAL IL-8 may promote a more pro-inflammatory 

alveolar milieu. Increased alveolar inflammation in females may account 

for both reduced progression from infection to severe sepsis through 

improved bacterial clearance, but in those who do progress to severe sepsis 

the exaggerated inflammatory response might result in increased organ 

dysfunction and account for poor outcome. Understanding gender 

determined differences in response to infection might highlight new 

therapies for sepsis and ALI. 

Funded by the UK Intensive Care Society and NI R&D Office. 

43. Capillary lactate in critical care 

D Soo*, J Baldwin*, N Miller-Biot † , E Shardlow*, E Davies † , P Bunting*, 

S Laha* 

*Lancashire Teaching Hospitals NHS Trust, Preston, UK. † University of 

Manchester, Manchester, UK 

S-14 

The measurement of lactate levels has an established role in the assessment 

of the critically ill patient, both in indicating risk of mortality, 1-3 and in 

guiding treatments such as entry into sepsis protocols. 4 Hand-held devices 

have been designed to measure lactate at the bedside. Analysis of capillary 

blood samples on such devices, if shown to be accurate, could have 

advantages over currently used methods, such as increased turn-around 

times which would facilitate decision making. The aim of this study was to 

ascertain whether capillary lactate analysed on a hand-held device can 

produce results that correlate sufficiently with the gold-standard method 

(arterial blood analysed by the laboratory) to be considered reliable. 

Adult patients admitted to the critical care unit of a teaching hospital, 

and requiring arterial lines as part of their normal care, were enrolled 

prospectively during the study period March-July 2011. From each patient 

capillary, arterial and venous samples were taken. Capillary samples were 

measured on the Roche ® Accutrend hand-held lactate analyser. Venous and 

arterial samples, taken by venepuncture and withdrawn from the arterial 

line respectively, were tested on the hand-held device and sent to the 

hospital's laboratory for testing (Roche ® Modular P Unit lactate analyser). 

Agreement between the lactate measurement methods were assessed 

using inter-method reliability coefficients (ICCs) and Bland-Altman plots. 

Correlation was estimated through calculations of r 2 . 

From a cohort of 36 patients, capillary lactate levels measured on the 

hand held device (range=1 to 4.6) showed poor agreement (ICC=0.16) and 

poor correlation (r 2 =0.34) with laboratory tested arterial samples 

(range=0.47 to 3.58 mmol/L). Results from venous blood analysed on the 

hand-held device compared with venous blood measured in the laboratory 

were analysed as part of the secondary outcomes. Agreement and 

correlation were better, though not statistically significant (ICC 0.75, limits 

of agreement -0.24 and 1.46, r 2 =0.84). 

The poor correlation between capillary measured lactate and the goldstandard, 

excludes the possibility for it to replace current practice. 

However, venous blood analysed on the hand-held lactate meter had better 

correlation with laboratory results. This is a promising finding and will be 

the subject of future research projects in the same department. 

References 

1. Bakker J, Gris P, Coffernils M et al. Serial blood lactate levels can predict the 

development of multiple organ failure following septic shock. Am J Surg 1996;171: 

221-26. 

2. Smith I, Kumar P, Molloy S et al. Base excess and lactate as prognostic indicators for 

patients admitted to the intensive care. Intensive Care Med 2001;27:74-83. 

3. Khosravani H, Shahpori R, Stelfox HT et al. Occurrence and adverse effect on outcome 

of hyperlactatemia in the critically ill. Crit Care 2009;13:90. 

4. Dellinger RP, Levy MM, Carlet JM et al. Surviving Sepsis Campaign: international 

guidelines for management of severe sepsis and septic shock. Crit Care Med 2008;36: 

296-327. 

44. Does the prophylactic use of Octenisan skin 

washes reduce the incidence of bacteraemias and 

MRSA acquisition in critical care 

C Spencer, D Orr, S Hallam, E Tillmans 

Lancashire Teaching Hospitals, Preston, UK 

Routine daily body-washes with the antiseptic, chlorhexidine, have been 

previously shown to be associated with a reduction in MRSA (methicillin 

resistant Staphylococcus aureus) and VRE (vancomycin resistant 

Enterococcus) acquisition and bacteraemia. 1 Octenisan ® (Schulke & Mayr, 

Germany) is an antiseptic in widespread clinical use as part of MRSA 

eradication therapy. The active ingredient, octenidine has a wide spectrum 

of antibacterial and antifungal action but is particularly active against 

MRSA without inducing resistance. 2 

We performed this retrospective, uncontrolled study in a 24-bedded 

mixed critical care unit with tertiary neurosciences, at Lancashire Teaching 

Hospitals. From 1st June 2009 to 1st June 2010 all elective and emergency 

patients admitted, were washed with soap and water. From 1st June 2010 

to 1st June 2011 all elective and emergency admissions were washed with 

soap and water only if visibly soiled, then washed from the neck down 

with Octenisan, with a contact time of three minutes before being washed 

off. Measured outcomes were: 



MRSA acquisition – defined as a patient with no previous history of 

MRSA, who had negative surveillance swabs (skin, nose, perineum) on 

unit admission, who later cultured MRSA from any site. 

ICU-acquired bacteraemias – defined as a positive blood culture, 

obtained >48 hours post admission to the unit. 

Chi squared test was used for testing for statistical significance. 

Soap and water Octenisan 

(2009/10) (2010/11) 

Patients admitted 1206 1225 

MRSA acquisitions 29 7 (p=0.0002) 

MRSA bacteraemias 3 0 

Total blood cultures taken 322 336 

>48 hours post ICU admission 

Number of bacteraemias 37 31 (p=0.4669) 

>48 hours post ICU admission 

The 76% reduction in MRSA acquisitions and reduction in bacteraemia 

may be due to reducing the bio-burden, or even eradication of MRSA, on 

patients skin, reducing risk of further transmission and colonisation. 

Infection control practices, including barrier nursing precautions, did not 

change across this period. It must be noted however, that MRSA 

bacteraemias in the hospital at large did reduce across this period, a 

possible confounding factor. 

ICU-acquired bacteraemias reduced, although non-significantly. The 

frequency of blood culture sampling did not change during the study 

period. The largest reduction in bacteraemias was mainly due to a 

reduction in coagulase negative staphylococcal (CNS) bacteraemias from 

14 to 8 per year (p=0.200). This may be due to a lower skin bio-burden of 

CNS leading to fewer inadvertent cultures of skin contaminants, or less 

opportunity for invasive CNS infection. 

This study shows that routine/prophylactic antiseptic washes with 

Octenisan may have a role in programs for MRSA reduction in critical care 

units. 

Acknowledgements: No funding, no involvement of Schulke-Mayr. 

References 

1. Climo M, Sepkowitz K, Zuccotti G et al. The effect of daily bathing with chlorhexidine 

on the acquisition of methicillin-resistant Staphylococcus aureus, vancomycin-resistant 

Enterococcus, and healthcare-associated bloodstream infections: Results of a quasiexperimental 

multicenter trial. Crit Care Med 2009;37:1858-65. 

2. Al-Doori Z, Goroncey-Bermes P, Gemmell CG et al. Low-level exposure of MRSA to 

octenidine dihydrochloride does not select for resistance. J Antimicrob Chemother 

2007;59:1280-81. 

45. Regionalisation of ICU and ECMO services in the 

UK; beliefs about the evidence, benefits and harm 

— a national survey 

N Stewart*, K Gunning † , BH Cuthbertson ‡ 

*Aberdeen Royal Infirmary, Aberdeen, UK. † Addenbrooke’s Hospital, 

Cambridge, UK. ‡ Sunnybrook Health Sciences Centre, Toronto, Canada 

Extra-corporeal membrane oxygenation (ECMO) has been used 

sporadically as rescue therapy for adults with severe acute respiratory 

failure in adults. During the recent H1N1 influenza pandemics existing 

ECMO capacity has often been saturated. We aimed to determine the views 

of Intensive Care clinicians’ on the development of adult ECMO services. 

A UK national survey of all members of the UK Intensive Care Society was 

conducted. 

A total of 2,148 participants were invited to complete the survey with 

691 respondents (32.7%). Among respondents: 65% believe adult ECMO 

services should be expanded; 42.5% of respondents agreed that ICU 

services in the UK should be regionalised while 63.8% agreed the UK 

should develop regional ventilatory care centres including ECMO services. 

Of these 52.8% believe the development of such centres would lead to 

improved outcomes despite only 38.1% agreeing that current evidence base 

supports the use of ECMO. Most (72%) agree there is a requirement for 

further trials in this area. Experience during H1N1 influenza pandemics 

was the factor respondents most frequently identified as driving ECMO 

expansion (61.1%). The majority (60.1%) believe that expanded ECMO 

service should be provided in 5-10 supra-regional centres. Patient safety, 

resources, guidelines and transportation of sick patients were also seen as 

important issues. 

In conclusion, there is support for centralisation of ICU services and for 

expansion in ECMO services for adults with severe acute respiratory failure 

in the UK. If expansion of ECMO services is envisaged, clinicians support 

appropriate funding, investment in transport services and development of 

national guidelines. 

46. Protocols for the prevention of contrast-induced 

nephropathy: a 2011 survey of intensive care 

units in the United Kingdom 

Strachan JM*, Crilley T † , Parvizi S † , DeVile MPJ ‡ 

*Royal Berkshire Hospital, Reading, UK. † Milton Keynes General Hospital, 

Milton Keynes, UK. ‡ John Radcliffe Hospital, Oxford, UK 

Computerised tomography is a common investigation on the intensive care 

unit (ICU), frequently exposing patients to intravenous contrast media. 

Contrast-induced nephropathy (CIN) is an important cause of renal failure 

in the critically ill, and significantly increases mortality. 1 However current 

evidence for measures taken to prevent CIN are conflicting and we 

hypothesised that wide variation in practice exists throughout the country 

with a lack of formal protocols. 

We therefore undertook a web-based survey to determine the existence 

of protocols on ICUs for the prevention of CIN and also to gauge current 

practice. We directed the survey at all units capable of taking level 3 

patients across the UK, as defined by the most recent Critical Care 

Directory (2008), via the Intensive Care Society website and by emailing 

individual hospitals. Ethical approval was not thought to be necessary. 

During April, May and June 2011 we received responses from 117 

individual ICUs from a possible 329 units; a 36% response rate. From these 

117 individual ICUs, 32 (27.4%) claimed to have a protocol while 85 

(72.6%) did not. Protocols were more likely in specialist ICUs – 10 of 17 

units (58.8%) – than teaching hospital ICUs – eight of 32 units (25% ) – or 

district general ICUs – 14 of 68 units (20.6%). Of the 32 units that claimed 

to have a protocol, 18 (56%) used N-acetylcysteine (NAC) in a variety of 

dosing regimens, and the remaining 14 (44%) did not use NAC. In units 

with a protocol 1.26% sodium bicarbonate was the preferred fluid type – 

used in 11 units (34%), followed by Hartmann’s solution – used in 10 units 

(31%) in a wide variety of volumes and regimen timings. Only five units 

(16%) with protocols did not use fluid boluses. Of the 85 units that did not 

have a protocol, no consensus on the available evidence was stated as the 

reason by 48 (41%) while 20 units (17%) felt this is a decision taken by 

radiology. Of these units without formal protocols, 17 (20%) still gave 

NAC, whereas 68 (80%) did not. A fluid regimen was used by 39 (46%) 

while 46 (54%) did not give fluid boluses at all. Themes from free text 

comments included the feeling that the evidence is not yet convincing for 

widespread use of standardised preventative measures as well as that taking 

a “risk benefit” approach, rather than using specific creatinine cut off 

values, ought to determine contrast use. 

Protocols for the prevention of CIN are not commonplace on ICUs in 

the UK. However it appears that many clinicians are thinking about CIN 

and freely prescribing some form of prophylaxis. More evidence is 

therefore needed to convince the majority of ICU physicians that to follow 

a standardised approach in order to prevent renal injury from contrast 

media is worthwhile. 

Acknowledgement: We acknowledge and thank the Intensive Care 

Society for promoting the survey online. None of the authors have any 

conflicts of interest to declare. 

Reference 

1. Lakhal K, Ehrmann S, Chaari A et al. Acute Kidney Injury Network definition of 

contrast-induced nephropathy in the critically ill: Incidence and outcome. J Crit Care 

Available online 6 July 2011; doi:10.1016/j.jcrc.2011.05.010. 



47. Decreased levels in elafin due to proteolytic 

cleavage may contribute to alveolar inflammation 

in the pulmonary compartment in patients 

with ALI 

A Kerrin, C O’Kane, M Shyamsundar, T Craig, DF McAuley, CC Taggart 

Queen’s University of Belfast, Northern Ireland 

Unregulated protease activity may drive dysregulated pulmonary 

inflammation implicated in acute lung injury (ALI). Elafin is a potent 

serine protease inhibitor produced locally in the lung by epithelial and 

inflammatory cells with anti-inflammatory properties. In this study we 

assessed the temporal changes in elafin concentration in patients with ALI 

and evaluate whether a decrease in elafin levels are due to proteolytic 

degradation. We also evaluated the ability of elafin to down-regulate 

inflammation in alveolar macrophages. 

Patients with ALI within 48 hours of onset of ALI (n=37), day 3 (n=19) 

and day 7 (n=9) as well as five healthy volunteers underwent 

bronchoalveolar lavage fluid (BALF). Elafin was measured by ELISA. To 

determine whether elafin was susceptible to proteolytic cleavage, western 

blot analysis of recombinant elafin was incubated with BALF ± protease 

inhibitors. Alveolar macrophages from healthy volunteers were isolated 

and pre-treated with 10 µg/mL elafin for one hour, followed by 24 hour 

stimulation with 100 ng/mL LPS. IL-8 was measured in supernatants by 

ELISA. 

Elafin was significantly increased at the onset of ALI compared to 

healthy volunteers (39±5 ng/mL vs 0.5±0.1 ng/ml; p


lungs were noted between the two MHI circuits. Tc-99m uptake was 

generally more in the right lung fields (62.7% and 63% respectively) than 

in the left lung fields (37.3% and 37% respectively) for all patients and was 

least in the left lower segments (4.3% and 6.9% respectively) on both 

occasions. No statistically significant differences in HR, MAP or C D 

were 

noted between the two MHI circuits. 

The Mapleson-C and Laerdal MHI circuits using PEEP of 7.5 cmH 2 

O 

and PIP of 25 cmH 2 

O in mechanically ventilated patients in the supine 

position proved to be equally effective with regards to airflow distribution 

through the tracheobronchial tree. The supine position however might not 

be optimal in the treatment of left lower lobe pathology with MHI as little 

airflow was observed to this area during this study. 

Acknowledgements: The researchers thank all the patients, medical, 

nursing and physiotherapy personnel of the multidisciplinary ICU, 

Universitas Hospital who participated in this project. Thanks also to 

Professor Anton Otto, Head of Nuclear Medicine, Universitas Hospital for 

his support to this project. This project was funded by the University of the 

Witwatersrand Faculty of Health Sciences Research Committee Individual 

Research Grant. 

References 

1. Berney S, Denehy L, Pretto J. Head-down tilt and manual hyperinflation enhance 

sputum clearance in patients who are intubated and ventilated. Aust J Physiother 

2004;50:9-14. 

2. Choi JSP, Jones AYM. Effects of manual hyperinflation and suctioning on respiratory 

mechanics in mechanically ventilated patients with ventilator-associated pneumonia. 

Aust J Physiother 2005;51:25-30. 

3. Savian C, Chan P, Paratz J. The effect of positive end-expiratory pressure level on peak 

expiratory flow during manual hyperinflation. Anesth Analg 2005;100:1112-16. DOI: 

10.1213/01.ANE.0000147505.98565.AC 

53. Outcomes and APACHE II scores for patients 

with alcoholic liver disease and ICU admission; 

a retrospective observational cohort study 

J Welbourne, K Gunning 

Addenbrookes Hospital, Cambridge, UK 

Analysis of the ICNARC database has shown that intensive care unit (ICU) 

admissions with alcoholic liver disease (ALD) increased from 0.65% in 

1996 to 1.35% in 2005. 1 The Office of National Statistics reports that 

alcohol related deaths rose from 6.9 per 100,000 in 1991 to 12.9 per 

100,000 in 2005. 2 Available data suggests very poor outcomes for patients 

with ALD admitted to ICU. 3 

A retrospective observational cohort study was performed between June 

2006 and June 2011 in a UK ICU with specialist hepatology care. This 

single specialist unit (‘JVF’) data has been compared to national data 

(Table 1). 

Number of ICU mortality Hospital Mean APACHE II 

patients mortality score 

ICNARC 118 43.2% 64.9% 20.0 

JVF data 46 28% p>0.05 41% p=0.005 20.03 p>0.05 

Table 1. National data 2005 and JVF data for patients with alcoholic hepatitis 

or alcoholic cirrhosis who are admitted to ICU. 

This study shows improved hospital mortality for patients with ALD 

admitted to a centre with hepatology care as compared to national data. 

Further prospective study is indicated to examine outcomes when patients 

with ALD admitted to general ICUs are transferred to a specialist 

hepatology centre. This is an area of interest as the number of patients with 

ALD admitted to ICU is increasing. 

References 

1. Welch C, Harrison D, Short A, Rowan K. The increasing burden of alcoholic liver 

disease on United Kingdom critical care units: secondary analysis of a high quality 

clinical database. J Health Serv Res Policy 2008;13 Suppl 2:40-44. 

2. Alcohol-related deaths in the United Kingdom, 2000-2009. Office of National Statistics. Jan 

2011. 

3. Mackle D, Swann. One year outcome of intensive care patients with decompensated 

alcoholic liver disease. Br J Anaesth 2006;97:496-98. 

55. Deep vein thrombosis (DVT) in critically ill patients 

R Moroi, M Takeda, T Harada, M Namiki, A Yaguchi 

Tokyo Women’s Medical University, Japan 

The diagnosis of DVT (deep vein thrombosis) is important to prevent 

pulmonary embolism (PE) which eventually causes death in hospitalised 

patients. Especially, there is a high incidence of DVT in critically ill 

patients, because almost all the patients in the ICU have risk factors for 

DVT and limitations of their activities of daily living due to unstable vital 

status, controlled with analgesia, or multiple injuries. However, the 

prophylaxis and the treatment for DVT are sometimes difficult for ICU 

patients because of their underlying disease such as intracranial 

hemorrhage, trauma and gastrointestinal hemorrhage. The aim of the 

present study is to evaluate the backgrounds of DVT patients in ICU and to 

assess the prophylaxis and the treatment for DVT in critically ill patients. 

Ninety-one ICU patients (57 men (63%), 34 women (37%); age 65 [49- 

77]) were included in this study. The duplex ultrasound scans (ALOKA ® , 

Tokyo) were performed within one week after admission to the ICU and 

DVT was diagnosed by duplex ultrasonography. D-dimer levels (µg/mL) 

were measured by latex agglutination test (Sekisui Medical ® , Tokyo) 

(normal


Quality parameter ETT (n=50) LMA (n=25) BVM (n=25) 

Before After P value Before After P value Before After P value 

Continuous 0 (0%) 50 (100%) 0 (0%) 25 (100%) 0 (0%) 0 (0%) 

compressions, n (%) 

Compression depth (mm) 44.39±13.3 44.42±13.1 0.978 44.24±13.7 45.52±13.1 0.565 48.53±14.9 53.20±17.3 0.103 

Compression rate 113.6±16.3 115.0±12.8 0.544 116.9±18.8 118.9±13.0 0.576 118.3±13.3 118.1±13.0 0.923 

Prop comp depth


Doctors Advanced clinical P value 

(n=114) 

practitioners 

(n=80) 

No flow time (sec) 221.7±80.6 177±49.7 0.672 

No flow ratio 0.19 (0.1,0.24) 0.16 (0.11, 0.29) 0.944 

Mean compression depth (mm) 42.37±11.9 41.28±12.8 0.366 

Proportions of compressions 0.17 (0.02, 0.52) 0.27 (0.04, 0.54) 0.233 

with depth

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