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Background Patients' anxiety on intensive care unit (ICU) admission is associated with subsequent deterioration. Objective To assess whether patients' fears/anxiety are predictive of new organ failure within 7 days of ICU admission. Methods In a prospective 3-center cohort study of noncomatose patients without delirium or invasive mechanical ventilation, 9 specific fears were evaluated through yes/no questions. Illness severity was assessed using the Simplified Acute Physiology Score II (SAPS II) and the Sequential Organ Failure Assessment (SOFA). Intensity of acute and chronic anxiety was assessed with the state and trait components of the State-Trait Anxiety Inventory (STAI). Patients were followed up for 7 days. Results From April 2014 to December 2017, 373 patients (median [IQR] age, 63 [48-74] years; 152 [40.8%] women; median (IQR) SAPS II, 27 [19-37]) were included. Feelings of vulnerability and fear of dying were reported by 203 (54.4%) and 172 (46.1%) patients, respectively. The STAIState score was 40 or greater in 192 patients (51.5%). Ninetyfour patients (25.2%) had new organ failure. Feelings of vulnerability (odds ratio, 1.96 [95% CI, 1.12-3.43]; P=.02) and absence of fear of dying (odds ratio, 2.38 [95% CI, 1.37-4.17]; P=.002) were associated with new organ failure after adjustment for STAI-State score (≥ 40), SAPS II, and SOFA score. Conclusion Absence of fear of dying is associated with new organ failure within the first 7 days after ICU admission. Fear of dying may protect against subsequent deterioration by mobilizing patients' homeostatic resources. [ABSTRACT FROM AUTHOR]

Author(s): Guillaume Geri [sup.1] [sup.3] [sup.4], Lucie Guillemet [sup.1], Florence Dumas [sup.2] [sup.3] [sup.4], Julien Charpentier [sup.1], Marion Antona [sup.5], Virginie Lemiale [sup.6], Wulfran Bougouin [sup.1] [sup.3] [sup.4], Lionel Lamhaut [...], Purpose Characteristics of acute kidney injury (AKI) occurring after out-of-hospital cardiac arrest (OHCA) are incompletely described. We aimed to evaluate the prevalence of AKI, identifying risk factors and assessing the impact of AKI on outcome after OHCA. Methods Single-center study between 2007 and 2012 in a cardiac arrest center in Paris, France. All consecutive OHCA patients with at least one weight measurement and one serum creatinine level available and treated by therapeutic hypothermia were included, except those with chronic kidney disease and those dead on arrival. AKI was defined as stage 3 of the Acute Kidney Injury Network (AKIN) classification. Main outcome was day-30 mortality. Factors associated with AKI occurrence and day-30 mortality were evaluated by logistic regression. Results 580 patients (71.3 % male, median age 59.3 years, initial shockable rhythm in 56.9 % of cases) were included in the analysis. AKI stage 3 occurred in 280 (48.3 %) patients. Age, male gender, resuscitation duration, post-resuscitation shock, public setting, and initial rhythm were associated with AKI stage 3. AKI stage 3 was associated with a significantly higher day-30 mortality rate [OR 1.60; 95 % CI (1.05, 2.43); p = 0.03]. No independent association between AKI and neurologic outcome was observed. At day 30, 67 patients had a normal kidney function (eGFR >75 mL/min/1.73 m.sup.2), and five remained dialysis-dependent. Patients with eGFR higher than 75 mL/min/1.73 m.sup.2 at day 30 were younger and more frequently male. Conclusion AKI stage 3 was frequent after OHCA and was associated with poorer outcome. Improvement strategies in post-resuscitation care should consider AKI as a potential target of treatment.

Author(s): Djillali Annane [sup.1], Marion Antona [sup.1], Blandine Lehmann [sup.2], Cecile Kedzia [sup.3], Sylvie Chevret [sup.4] Author Affiliations: (1) grid.50550.35, 0000 0001 2175 4109, General ICU, Raymond Poincaré Hospital, AP-HP, [...], Purpose To analyze the hurdles in implementing a randomized trial of corticosteroids for severe 2009 H1N1 influenza infections. Methods This was an investigator-led, multicenter, randomized, placebo-controlled, double-blind trial of corticosteroids in ICU patients with 2009 H1N1 influenza pneumonia requiring mechanical ventilation. The feasibility of and hurdles in designing and initiating a phase III trial in a short-lived pandemic crisis were analyzed. The regulatory agency and ethics committee approved the study's scientific, financial, and ethical aspects within 4 weeks. Hydrocortisone and placebo were prepared centrally and shipped to participating hospitals within 6 weeks. The inclusion period started on November 9, 2009. Results From August 1, 2009 to March 8, 2010, only 205/224 ICU patients with H1N1 infections required mechanical ventilation. The peak of the wave was missed by 2-3 weeks and only 26 patients were randomized. The two main reasons for non-inclusion were patients' admission before the beginning of the trial and ICU personnel overwhelmed by clinical duties. Parallel rather than sequential regulatory and ethics approval, and preparation and masking of study drugs by local pharmacists would have allowed the study to start 1 month earlier and before the peak of the 'flu' wave. A dedicated research team in each participating center would have increased the ratio of screened to randomized patients. Conclusion This report highlights the main hurdles in implementing a randomized trial for a pandemic critical illness and proposes solutions for future trials.

Background and purpose: Deep sedation is associated with acute brain dysfunction and increased mortality. We had previously shown that early-assessed brainstem reflexes may predict outcome in deeply sedated patients. The primary objective was to determine whether patterns of brainstem reflexes might predict mortality in deeply sedated patients. The secondary objective was to generate a score predicting mortality in these patients. Methods: Observational prospective multicenter cohort study of 148 non-brain injured deeply sedated patients, defined by a Richmond Assessment sedation Scale (RASS) <-3. Brainstem reflexes and Glasgow Coma Scale were assessed within 24 hours of sedation and categorized using latent class analysis. The Full Outline Of Unresponsiveness score (FOUR) was also assessed. Primary outcome measure was 28-day mortality. A “Brainstem Responses Assessment Sedation Score” (BRASS) was generated. Results: Two distinct sub-phenotypes referred as homogeneous and heterogeneous brainstem reactivity were identified (accounting for respectively 54.6% and 45.4% of patients). Homogeneous brainstem reactivity was characterized by preserved reactivity to nociceptive stimuli and a partial and topographically homogenous depression of brainstem reflexes. Heterogeneous brainstem reactivity was characterized by a loss of reactivity to nociceptive stimuli associated with heterogeneous brainstem reflexes depression. Heterogeneous sub-phenotype was a predictor of increased risk of 28-day mortality after adjustment to Simplified Acute Physiology Score-II (SAPS-II) and RASS (Odds Ratio [95% confidence interval] = 6.44 [2.63–15.8]; p<0.0001) or Sequential Organ Failure Assessment (SOFA) and RASS (OR [95%CI] = 5.02 [2.01–12.5]; p = 0.0005). The BRASS (and marginally the FOUR) predicted 28-day mortality (c-index [95%CI] = 0.69 [0.54–0.84] and 0.65 [0.49–0.80] respectively). Conclusion: In this prospective cohort study, around half of all deeply sedated critically ill patients displayed an early particular neurological sub-phenotype predicting 28-day mortality, which may reflect a dysfunction of the brainstem. [ABSTRACT FROM AUTHOR]