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Brainstem responses can predict death and delirium in sedated patients in intensive care unit*

Sharshar, Tarek MD, PhD; Porcher, Raphaël PhD; Siami, Shidasp MD; Rohaut, Benjamim MD; Bailly-Salin, Juliette MD; Hopkinson, Nicholas S. MD, PhD; Clair, Bernard MD; Guidoux, Celine MD; Iacobone, Emanuele MD; Sonneville, Romain MD; Polito, Andrea MD; Aboab, Jerome MD; Gaudry, Stephane MD; Morla, Olivier MD; Amouyal, Grégory MD; Azuar, Julien MD; Allary, Jérémy MD; Vieillard-Baron, Antoine MD, PhD; Wolff, Michel MD; Cariou, Alain MD; Annane, Djillali MD, PhD; for the Paris-Ouest Study Group on Neurological Effect of Sedation (POSGNES)

Critical Care Medicine:
doi: 10.1097/CCM.0b013e31821b843b
Neurologic Critical Care
Abstract

Objectives: In critically ill patients, the assessment of neurologic function can be difficult because of the use of sedative agents. It is not known whether neurologic signs observed under sedation can predict short-term outcomes. The objective of this study was to assess whether abnormal brainstem responses within the first 24 hrs of sedation are associated with mortality and altered mental status postsedation.

Design: Observational prospective study including an initial single-center and a subsequent multicenter study to develop and then validate the prognostic models.

Setting: Three mixed and two medical intensive care units.

Patients: Mechanically ventilated intensive care unit patients sedated with midazolam (± sufentanyl).

Interventions: Neurologic examination including the Glasgow Coma Scale, the Assessment to Intensive Care Environment score, cranial nerve examination, response to noxious stimuli, and the cough reflex was performed.

Measurements and Main Results: Seventy-two patients were included in the initial group and 72 in a subsequent validation study. Neurologic responses were independent of sedative dose. Twenty-two patients in the development cohort and 21 (29%) in the validation group died within 28 days of inclusion. Adjusted for Simplified Acute Physiology Score II score, absent cough reflex was independently associated with 28-day mortality in the development (adjusted odds ratio [OR], 7.80; 95% confidence interval [CI], 2.00–30.4; p = .003) and validation groups (adjusted OR, 5.44; 95% CI, 1.35–22.0; p = .017). Absent oculocephalic response, adjusted for Simplified Acute Physiology Score II score, was independently associated with altered mental status after the withdrawal of sedation in the development (adjusted OR, 4.54; 95% CI, 1.34–15.4; p = .015) and validation groups (adjusted OR, 6.10; 95% CI, 1.18–25.5; p = .012).

Conclusions: Assessment of brainstem responses is feasible in sedated critically ill patients and loss of selected responses is predictive of mortality and altered mental status.

Author Information

From the General Intensive Care Unit (TS, BR, JB-S, AP, J. Aboab, OM, GA, J. Azuar, J. Allary, DA), Raymond Poincaré Teaching Hospital (AP-HP), University of Versailles Saint-Quentin en Yvelines, Garches, France; Biostatistics and Medical Computer Science Department (RP), Saint-Louis Teaching Hospital (AP-HP), Paris, France; General Intensive Care Unit (SS), Etampes, France; Respiratory Muscle Laboratory (NSH), National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom; Medical Intensive Care Unit (CG), Ambroise Paré Teaching Hospital (AP-HP), University of Versailles Saint-Quentin en Yvelines, Boulogne, France; General Intensive Care Unit (EI), Fermo Hospital, Fermo, Italy; Medical Intensive Care Unit (RS, SG, MW), Bichat-Claude Bernard Teaching Hospital (AP-HP), University of Paris VII, Paris, France; Medical Intensive Care Unit (AC), Cochin Teaching Hospital (AP-HP), University of Paris V, Paris, France.

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The authors have not disclosed any potential conflicts of interest.

For information regarding this article, E-mail: tarek.sharshar@rpc.aphp.fr

© 2011 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins