Brainstem response patterns in deeply-sedated critically-ill patients predict 28-day mortality.

Autor: Rohaut B; Neurological Departement Intensive Care Unit, Assistance Publique - Hôpitaux de Paris (AP-HP), Pitié-Salpétrière Hospital, Paris, France.; Sorbonne University, UPMC Univ Paris 06, Faculté de Médecine Pitié-Salpêtrière, Paris, France.; Institut du Cerveau et de la Moelle épinière, ICM, PICNIC Lab, Paris, France.; INSERM, U 1127, Paris, France., Porcher R; Center for Clinical Epidemiology, AP-HP, Hôtel Dieu Hospital, Descartes University, Paris, France., Hissem T; General Intensive Care Unit, Sud Essonne Hospital, Etampes, France., Heming N; General Intensive Care Unit, AP-HP, Raymond Poincaré Hospital, University of Versailles Saint-Quentin en Yvelines, Garches, France., Chillet P; General Intensive Care Unit, Chalons en Champagne Hospital, Chalons en Champagne, France., Djedaini K; General Intensive Care Unit, Geoffroy Saint-Hilaire Hospital, Paris France., Moneger G; General Intensive Care Unit, AP-HP, Raymond Poincaré Hospital, University of Versailles Saint-Quentin en Yvelines, Garches, France., Kandelman S; Department of Anesthesiology and Intensive Care Unit, AP-HP, Beaujon-Claude Bernard Hospital, Diderot University, Paris, France., Allary J; Department of Anesthesiology and Intensive Care Unit, AP-HP, Beaujon-Claude Bernard Hospital, Diderot University, Paris, France., Cariou A; Intensive Care Unit, AP-HP, Cochin Hospital, Descartes University, Paris, France., Sonneville R; Medical Intensive Care Unit, AP-HP, Bichat-Claude Bernard Hospital, Diderot University, Paris, France., Polito A; General Intensive Care Unit, AP-HP, Raymond Poincaré Hospital, University of Versailles Saint-Quentin en Yvelines, Garches, France., Antona M; Surgical Intensive Care Unit, AP-HP, Cochin Hospital, Descartes University, Paris, France., Azabou E; Department of Physiology, AP-HP, Raymond Poincaré Hospital, University of Versailles Saint-Quentin en Yvelines, Garches, France., Annane D; General Intensive Care Unit, AP-HP, Raymond Poincaré Hospital, University of Versailles Saint-Quentin en Yvelines, Garches, France., Siami S; General Intensive Care Unit, Sud Essonne Hospital, Etampes, France., Chrétien F; Laboratory of Human Histopathology and Animal Models, Pasteur Institut, Paris, France.; Department of Neuropathology, Saint Anne Hospital, Descartes University, Paris, France., Mantz J; Laboratory of Human Histopathology and Animal Models, Pasteur Institut, Paris, France.; Department of Anesthesiology and Intensive Care Unit, AP-HP, Georges Pompidou European Hospital, Descartes University, Paris, France., Sharshar T; General Intensive Care Unit, AP-HP, Raymond Poincaré Hospital, University of Versailles Saint-Quentin en Yvelines, Garches, France.; Laboratory of Human Histopathology and Animal Models, Pasteur Institut, Paris, France.
Jazyk: angličtina
Zdroj: PloS one [PLoS One] 2017 Apr 25; Vol. 12 (4), pp. e0176012. Date of Electronic Publication: 2017 Apr 25 (Print Publication: 2017).
DOI: 10.1371/journal.pone.0176012
Abstrakt: 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.
Databáze: MEDLINE
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