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Heming N, Mazeraud A, Azabou E, Moine P, Annane D. Vasopressor Therapy and the Brain: Dark Side of the Moon. Front Med (Lausanne) 2020; 6:317. [PMID: 31998736 PMCID: PMC6966606 DOI: 10.3389/fmed.2019.00317] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 12/13/2019] [Indexed: 12/14/2022] Open
Abstract
Sepsis, a leading cause of morbidity and mortality, is caused by a deregulated host response to pathogens, and subsequent life-threatening organ dysfunctions. All major systems, including the cardiovascular, respiratory, renal, hepatic, hematological, and the neurological system may be affected by sepsis. Sepsis associated neurological dysfunction is triggered by multiple factors including neuro-inflammation, excitotoxicity, and ischemia. Ischemia results from reduced cerebral blood flow, caused by extreme variations of blood pressure, occlusion of cerebral vessels, or more subtle defects of the microcirculation. International guidelines comprehensively describe the initial hemodynamic management of sepsis, revolving around the normalization of systemic hemodynamics and of arterial lactate. By contrast, the management of sepsis patients suffering from brain dysfunction is poorly detailed, the only salient point being mentioned is that sedation and analgesia should be optimized. However, sepsis and the hemodynamic consequences thereof as well as vasopressors may have severe untoward neurological consequences. The current review describes the general neurological complications, as well as the consequences of vasopressor therapy on the brain and its circulation and addresses methods for cerebral monitoring during sepsis.
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Affiliation(s)
- Nicholas Heming
- General Intensive Care Unit, Raymond Poincaré Hospital, Garches, France.,U1173 Lab Inflammation and Infection, University of Versailles SQY-Paris Saclay - INSERM, Montigny-le-Bretonneux, France
| | - Aurélien Mazeraud
- Department of Neuro-Anesthesiology and Intensive Care Medicine, Sainte-Anne Teaching Hospital, Paris-Descartes University, Paris, France
| | - Eric Azabou
- U1173 Lab Inflammation and Infection, University of Versailles SQY-Paris Saclay - INSERM, Montigny-le-Bretonneux, France.,Department of Physiology, Assistance Publique-Hôpitaux de Paris, Raymond-Poincaré Hospital, Garches, France
| | - Pierre Moine
- General Intensive Care Unit, Raymond Poincaré Hospital, Garches, France.,U1173 Lab Inflammation and Infection, University of Versailles SQY-Paris Saclay - INSERM, Montigny-le-Bretonneux, France
| | - Djillali Annane
- General Intensive Care Unit, Raymond Poincaré Hospital, Garches, France.,U1173 Lab Inflammation and Infection, University of Versailles SQY-Paris Saclay - INSERM, Montigny-le-Bretonneux, France
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2
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Rosenblatt K, Walker KA, Goodson C, Olson E, Maher D, Brown CH, Nyquist P. Cerebral Autoregulation-Guided Optimal Blood Pressure in Sepsis-Associated Encephalopathy: A Case Series. J Intensive Care Med 2019; 35:1453-1464. [PMID: 30760173 PMCID: PMC6692246 DOI: 10.1177/0885066619828293] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Impaired cerebral autoregulation and cerebral hypoperfusion may play a critical role in the high morbidity and mortality in patients with sepsis-associated encephalopathy (SAE). Bedside assessment of cerebral autoregulation may help individualize hemodynamic targets that optimize brain perfusion. We hypothesize that near-infrared spectroscopy (NIRS)-derived cerebral oximetry can identify blood pressure ranges that enhance autoregulation in patients with SAE and that disturbances in autoregulation are associated with severity of encephalopathy. METHODS Adult patients with acute encephalopathy directly attributable to sepsis were followed using NIRS-based multimodal monitoring for 12 consecutive hours. We used the correlation in time between regional cerebral oxygen saturation and mean arterial pressure (MAP) to determine the cerebral oximetry index (COx) as a measure of cerebral autoregulation. Autoregulation curves were constructed for each patient with averaged COx values sorted by MAP in 3 sequential 4-hour periods; the optimal pressure (MAPOPT), defined as the MAP associated with most robust autoregulation (lowest COx), was identified in each period. Severity of encephalopathy was measured with Glasgow coma scale (GCS). RESULTS Six patients with extracranial sepsis met the stringent criteria specified, including no pharmacological sedation or neurologic premorbidity. Optimal MAP was identified in all patients and ranged from 55 to 115 mmHg. Additionally, MAPOPT varied within individual patients over time during monitoring. Disturbed autoregulation, based on COx, was associated with worse neurologic status (GCS < 13) both with and without controlling for age and severity of sepsis (adjusted odds ratio [OR]: 2.11; 95% confidence interval [CI]: 1.77-2.52; P < .001; OR: 2.97; 95% CI: 1.63-5.43; P < .001). CONCLUSIONS In this high-fidelity group of patients with SAE, continuous, NIRS-based monitoring can identify blood pressure ranges that improve autoregulation. This is important given the association between cerebral autoregulatory function and severity of encephalopathy. Individualizing blood pressure goals using bedside autoregulation monitoring may better preserve cerebral perfusion in SAE than current practice.
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Affiliation(s)
- Kathryn Rosenblatt
- Department of Anesthesiology and Critical Care Medicine, 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Neurology, 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Keenan A Walker
- Department of Neurology, 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carrie Goodson
- Department of Pulmonary and Critical Care, 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elsa Olson
- Department of Anesthesiology and Critical Care Medicine, 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dermot Maher
- Department of Anesthesiology and Critical Care Medicine, 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Charles H Brown
- Department of Anesthesiology and Critical Care Medicine, 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Paul Nyquist
- Department of Anesthesiology and Critical Care Medicine, 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Neurology, 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Azabou E, Navarro V, Kubis N, Gavaret M, Heming N, Cariou A, Annane D, Lofaso F, Naccache L, Sharshar T. Value and mechanisms of EEG reactivity in the prognosis of patients with impaired consciousness: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:184. [PMID: 30071861 PMCID: PMC6091014 DOI: 10.1186/s13054-018-2104-z] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 06/22/2018] [Indexed: 12/21/2022]
Abstract
Background Electroencephalography (EEG) is a well-established tool for assessing brain function that is available at the bedside in the intensive care unit (ICU). This review aims to discuss the relevance of electroencephalographic reactivity (EEG-R) in patients with impaired consciousness and to describe the neurophysiological mechanisms involved. Methods We conducted a systematic search of the term “EEG reactivity and coma” using the PubMed database. The search encompassed articles published from inception to March 2018 and produced 202 articles, of which 42 were deemed relevant, assessing the importance of EEG-R in relationship to outcomes in patients with impaired consciousness, and were therefore included in this review. Results Although definitions, characteristics and methods used to assess EEG-R are heterogeneous, several studies underline that a lack of EEG-R is associated with mortality and unfavorable outcome in patients with impaired consciousness. However, preserved EEG-R is linked to better odds of survival. Exploring EEG-R to nociceptive, auditory, and visual stimuli enables a noninvasive trimodal functional assessment of peripheral and central sensory ascending pathways that project to the brainstem, the thalamus and the cerebral cortex. A lack of EEG-R in patients with impaired consciousness may result from altered modulation of thalamocortical loop activity by afferent sensory input due to neural impairment. Assessing EEG-R is a valuable tool for the diagnosis and outcome prediction of severe brain dysfunction in critically ill patients. Conclusions This review emphasizes that whatever the etiology, patients with impaired consciousness featuring a reactive electroencephalogram are more likely to have a favorable outcome, whereas those with a nonreactive electroencephalogram are prone to having an unfavorable outcome. EEG-R is therefore a valuable prognostic parameter and warrants a rigorous assessment. However, current assessment methods are heterogeneous, and no consensus exists. Standardization of stimulation and interpretation methods is needed.
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Affiliation(s)
- Eric Azabou
- Department of Physiology and Department of Critical Care Medicine, Raymond Poincaré Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Inserm UMR 1173 Infection and Inflammation, University of Versailles Saint Quentin (UVSQ), University Paris-Saclay, Garches, Paris, France. .,Clinical Neurophysiology Unit, Raymond Poincaré Hospital - Assistance - Publique Hôpitaux de Paris, INSERM U1173, University of Versailles-Saint Quentin (UVSQ), 104 Boulevard Raymond Poincaré, Garches, 92380, Paris, France.
| | - Vincent Navarro
- Department of Clinical Neurophysiology, Pitié-Salpêtrière Hospital, AP-HP, Inserm UMRS 1127, CNRS UMR 7225, Sorbonne Universities, Université Pierre et Marie Curie - UPMC Université Paris 06, Paris, France
| | - Nathalie Kubis
- Department of Clinical Physiology, Lariboisière Hospital, AP-HP, Inserm U965, University of Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Martine Gavaret
- Department of Clinical Neurophysiology, Sainte-Anne Hospital, Inserm U894, University Paris-Descartes, Paris, France
| | - Nicholas Heming
- Department of Physiology and Department of Critical Care Medicine, Raymond Poincaré Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Inserm UMR 1173 Infection and Inflammation, University of Versailles Saint Quentin (UVSQ), University Paris-Saclay, Garches, Paris, France
| | - Alain Cariou
- Medical ICU, Cochin Hospital, AP-HP, Paris Cardiovascular Research Center, INSERM U970, Université Paris Descartes Sorbonne Paris Cité, Paris, France
| | - Djillali Annane
- Department of Physiology and Department of Critical Care Medicine, Raymond Poincaré Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Inserm UMR 1173 Infection and Inflammation, University of Versailles Saint Quentin (UVSQ), University Paris-Saclay, Garches, Paris, France
| | - Fréderic Lofaso
- Department of Physiology and Department of Critical Care Medicine, Raymond Poincaré Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Inserm UMR 1173 Infection and Inflammation, University of Versailles Saint Quentin (UVSQ), University Paris-Saclay, Garches, Paris, France
| | - Lionel Naccache
- Department of Clinical Neurophysiology, Pitié-Salpêtrière Hospital, AP-HP, Inserm UMRS 1127, CNRS UMR 7225, Sorbonne Universities, Université Pierre et Marie Curie - UPMC Université Paris 06, Paris, France
| | - Tarek Sharshar
- Department of Neuro-Intensive Care Medicine, Sainte-Anne Hospital, Paris-Descartes University, Paris, France
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Azabou E, Rohaut B, Heming N, Magalhaes E, Morizot-Koutlidis R, Kandelman S, Allary J, Moneger G, Polito A, Maxime V, Annane D, Lofaso F, Chrétien F, Mantz J, Porcher R, Sharshar T. Early impairment of intracranial conduction time predicts mortality in deeply sedated critically ill patients: a prospective observational pilot study. Ann Intensive Care 2017; 7:63. [PMID: 28608136 PMCID: PMC5468361 DOI: 10.1186/s13613-017-0290-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 06/02/2017] [Indexed: 12/21/2022] Open
Abstract
Background Somatosensory (SSEP) and brainstem auditory (BAEP) evoked potentials are neurophysiological tools which, respectively, explore the intracranial conduction time (ICCT) and the intrapontine conduction time (IPCT). The prognostic values of prolonged cerebral conduction times in deeply sedated patients have never been assessed. Sedated patients are at risk of developing new neurological complications, undetected. In this prospective observational bi-center pilot study, we investigated whether early impairment of SSEP’s ICCT and/or BAEP’s IPCT could predict in-ICU mortality or altered mental status (AMS), in deeply sedated critically ill patients. Methods SSEP by stimulation of the median nerve and BAEP were assessed in critically ill patients receiving deep sedation on day 3 following ICU admission. Deep sedation was defined by a Richmond Assessment sedation Scale (RASS) <−3. Mean left- and right-side ICCT and IPCT were measured for each patient. Primary and secondary outcomes were, respectively, in-ICU mortality and AMS defined as the occurrence of delirium and/or delayed awakening after discontinuation of sedation. Results Eighty-six patients were studied of which 49 (57%) were non-brain-injured and 37 (43%) were brain-injured. Impaired ICCT was a predictor of in-ICU mortality after adjustment on the global Sequential Organ Failure Assessment score (SOFA) [OR (95% CI) = 2.69 (1.05–6.85); p = 0.039] and on the non-neurological SOFA components [2.67 (1.05–6.81); p = 0.040]. IPCT was more frequently delayed in the subgroup of patients who developed post-sedation AMS (24%) compared those without AMS (0%). However, this difference did not reach statistical significance (p = 0.053). Impairment rates of ICCT and IPCT were not found to be significantly different between non-brain- and brain-injured subgroups of patients. Conclusion In critically ill patients receiving deep sedation, early ICCT impairment was associated with mortality. Somatosensory and brainstem auditory evoked potentials may be useful early warning indicators of brain dysfunction as well as prognostic markers in deeply sedated critically ill patients.
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Affiliation(s)
- Eric Azabou
- Department of Physiology - Assistance Publique Hôpitaux de Paris, Raymond-Poincaré Hospital, INSERM U 1179, University of Versailles Saint-Quentin en Yvelines, Garches, France.,General Intensive Care Unit - Assistance Publique Hôpitaux de Paris, Raymond-Poincaré Hospital, INSERM U 1173, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - Benjamin Rohaut
- Department of Neurology, Intensive Care Unit, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France.,UPMC Univ. Paris 06, Faculté de Médecine Pitié-Salpêtrière, Sorbonne Universités, Paris, France
| | - Nicholas Heming
- General Intensive Care Unit - Assistance Publique Hôpitaux de Paris, Raymond-Poincaré Hospital, INSERM U 1173, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - Eric Magalhaes
- General Intensive Care Unit - Assistance Publique Hôpitaux de Paris, Raymond-Poincaré Hospital, INSERM U 1173, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - Régine Morizot-Koutlidis
- Department of Neurology, Intensive Care Unit, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France.,UPMC Univ. Paris 06, Faculté de Médecine Pitié-Salpêtrière, Sorbonne Universités, Paris, France
| | - Stanislas Kandelman
- Department of Anesthesiology and Intensive Care Medicine - Beaujon Hospital, University of Denis Diderot, Clichy, France
| | - Jeremy Allary
- Department of Anesthesiology and Intensive Care Medicine - Beaujon Hospital, University of Denis Diderot, Clichy, France
| | - Guy Moneger
- General Intensive Care Unit - Assistance Publique Hôpitaux de Paris, Raymond-Poincaré Hospital, INSERM U 1173, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - Andrea Polito
- General Intensive Care Unit - Assistance Publique Hôpitaux de Paris, Raymond-Poincaré Hospital, INSERM U 1173, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - Virginie Maxime
- General Intensive Care Unit - Assistance Publique Hôpitaux de Paris, Raymond-Poincaré Hospital, INSERM U 1173, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - Djillali Annane
- General Intensive Care Unit - Assistance Publique Hôpitaux de Paris, Raymond-Poincaré Hospital, INSERM U 1173, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - Frederic Lofaso
- Department of Physiology - Assistance Publique Hôpitaux de Paris, Raymond-Poincaré Hospital, INSERM U 1179, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - Fabrice Chrétien
- Laboratory of Human Histopathology and Animal Models, Institut Pasteur, 28, rue du Dr Roux, 75015, Paris, France
| | - Jean Mantz
- Laboratory of Human Histopathology and Animal Models, Institut Pasteur, 28, rue du Dr Roux, 75015, Paris, France.,Department of Anesthesiology and Intensive Care Medicine - European Hospital Georges Pompidou, Paris Descartes University, Paris, France
| | - Raphael Porcher
- Center for Clinical Epidemiology - Assistance Publique Hôpitaux de Paris, Hotel Dieu Hospital, INSERM U1153, University Paris Descartes, Paris, France
| | - Tarek Sharshar
- General Intensive Care Unit - Assistance Publique Hôpitaux de Paris, Raymond-Poincaré Hospital, INSERM U 1173, University of Versailles Saint-Quentin en Yvelines, Garches, France. .,Laboratory of Human Histopathology and Animal Models, Institut Pasteur, 28, rue du Dr Roux, 75015, Paris, France. .,General Intensive Care Medicine, Raymond Poincaré Hospital (AP-HP), University of Versailles Saint-Quentin en Yvelines, 104, Boulevard Raymond Poincaré, 92380, Garches, France.
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Neurophysiological assessment of brain dysfunction in critically ill patients: an update. Neurol Sci 2017; 38:715-726. [PMID: 28110410 DOI: 10.1007/s10072-017-2824-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 01/16/2017] [Indexed: 01/08/2023]
Abstract
The aim of this review was to provide up-to-date information about the usefulness of clinical neurophysiology testing in the management of critically ill patients. Evoked potentials (EPs) and electroencephalogram (EEG) are non-invasive clinical neurophysiology tools that allow an objective assessment of the central nervous system's function at the bedside in intensive care unit (ICU). These tests are quite useful in diagnosing cerebral complications, and establishing the vital and functional prognosis in ICU. EEG keeps a particularly privileged importance in detecting seizures phenomena such as subclinical seizures and non-convulsive status epilepticus. Quantitative EEG (QEEG) analysis techniques commonly called EEG Brain mapping can provide obvious topographic displays of digital EEG signals characteristics, showing the potential distribution over the entire scalp including filtering, frequency, and amplitude analysis and color mapping. Evidences of usefulness of QEEG for seizures detection in ICU are provided by several recent studies. Furthermore, beyond detection of epileptic phenomena, changes of some QEEG panels are early warning indicators of sedation level as well as brain damage or dysfunction in ICU. EPs offer the opportunity for assessing brainstem's functional integrity, as well as subcortical and cortical brain areas. A multimodal use, combining EEG and various modalities of EPs is recommended since this allows a more accurate functional exploration of the brain and helps caregivers to tailor therapeutic measures according to neurological worsening trends and to anticipate the prognosis in ICU.
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LeBlanc JM, Dasta JF, Kane-Gill SL. Role of the Bispectral Index in Sedation Monitoring in the ICU. Ann Pharmacother 2016; 40:490-500. [PMID: 16492796 DOI: 10.1345/aph.1e491] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objective: To review and critique evidence for the use of the bispectral index (BIS) in intensive care unit (ICU) patients. Data Sources: A computer search of English-language articles in MEDLINE (1966–July 2005), International Pharmaceutical Abstracts (1971–July 2005), and Scientific Citation Index Expanded (1980–July 2005) was conducted. A manual search of abstracts was also performed using the key search terms BIS, sedation, and critical care. Study Selection and Data Extraction: Case series, letters, editorials, and clinical studies that evaluated BIS in ICU patients were considered for inclusion. Data Synthesis: Nineteen studies comparing the BIS with sedation scales were evaluated, revealing that the BIS trends lower with increasing sedation. The BIS appeared to correlate better when sedation scores were grouped rather than individual values. However, correlations between BIS and subjective scales were low in most studies (r2 0.21–0.93). Additionally, there was poor correlation between drug dosage and the BIS. Randomized, controlled trials demonstrating improved outcomes with BIS monitoring have not been reported. Conclusions: Interpreting literature on the usefulness of the BIS in the ICU is difficult for reasons that include heterogeneous populations, different methods of collecting BIS data, and use of different versions of BIS software and hardware. Outcomes data are lacking. The 2002 Society of Critical Care Medicine Sedation Guidelines recommendation that more data are needed before the BIS should be used routinely in the ICU remains unchanged. We recommend that further studies be conducted to determine the optimal method of obtaining BIS data and evaluate the impact of the BIS on relevant patient outcomes.
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Affiliation(s)
- Jaclyn M LeBlanc
- College of Pharmacy, The Ohio State University, Columbus, 43210, USA
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Lu CX, Qiu T, Tong HS, Liu ZF, Su L, Cheng B. Peripheral T-lymphocyte and natural killer cell population imbalance is associated with septic encephalopathy in patients with severe sepsis. Exp Ther Med 2016; 11:1077-1084. [PMID: 26998040 DOI: 10.3892/etm.2016.3000] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 12/21/2015] [Indexed: 12/20/2022] Open
Abstract
Septic encephalopathy (SE) is a diffuse cerebral dysfunction resulting from a systemic inflammatory response, and is associated with an increased risk of mortality. The pathogenesis of SE is complex and multifactorial, but unregulated immune imbalance may be an important factor. The current retrospective study examined the clinical data of 86 patients with severe sepsis who were admitted to the Intensive Care Unit at Zhongshan Hospital, Xiamen University (Xiamen, China) from January, 2014 to January, 2015. The patients were assigned to SE and non-SE patient groups according to the presence or absence of SE. The proportion of T-lymphocyte subsets and natural killer (NK) cells in the immune cell population, representing the function of the immune system, were analyzed for their association with SE and compared with other clinical predictors and biomarkers. The incidence of SE in the patients was 39.5%, and this group demonstrated higher mortality rates (38 vs. 10% in non-SE patients; P=0.001). Univariate analysis revealed that the SE patients reported a lower percentage of cluster of differentiation 4+(CD4+) T-lymphocytes (51.67±7.12 vs. 60.72±3.70% in non-SE patients; P<0.01), a lower CD4+/cluster of differentiation 8+(CD8+) ratio (1.59±0.32 vs. 1.85±0.26% in non-SE patients; P<0.01) and a higher percentage of NK cells (11.80±1.44 vs. 9.19±2.36% in non-SE patients; P<0.01). Using a binary logistic regression model, the Acute Physiology and Chronic Health Evaluation II score and the percentage of CD4+ T-lymphocytes were demonstrated to be independently associated with SE (respectively, P=0.012 and OR, 4.763; P=0.005 and OR, 0.810). An area under the curve analysis of a receiver operating characteristic curve of the two indicators revealed that these were equally powerful measures in prediction of SE (Z=1.247, P>0.05). The present results confirm that SE leads to higher mortality in patients with severe sepsis, and demonstrate that immune imbalance is important in the development of SE. The proportion of CD4+ T-lymphocytes present were revealed in the current study to be a powerful predictor of SE in patients with severe sepsis.
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Affiliation(s)
- Cheng-Xiang Lu
- Department of Intensive Care Unit, Affiliated General Hospital of Guangzhou Military Command of Southern Medical University, Guangzhou, Guangdong 510515, P.R. China; Department of Intensive Care Unit, Zhongshan Hospital Xiamen University, Xiamen, Fujian 361004, P.R. China
| | - Ting Qiu
- Department of Neurology, Zhongshan Hospital Xiamen University, Xiamen, Fujian 361004, P.R. China
| | - Hua-Sheng Tong
- Department of Intensive Care Unit, General Hospital of Guangzhou Military Command, Guangzhou, Guangdong 510010, P.R. China
| | - Zhi-Feng Liu
- Department of Intensive Care Unit, General Hospital of Guangzhou Military Command, Guangzhou, Guangdong 510010, P.R. China
| | - Lei Su
- Department of Intensive Care Unit, Affiliated General Hospital of Guangzhou Military Command of Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Biao Cheng
- Department of Plastic Surgery, Affiliated General Hospital of Guangzhou Military Command of Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
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Hosokawa K, Gaspard N, Su F, Oddo M, Vincent JL, Taccone FS. Clinical neurophysiological assessment of sepsis-associated brain dysfunction: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:674. [PMID: 25482125 PMCID: PMC4277650 DOI: 10.1186/s13054-014-0674-y] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 11/17/2014] [Indexed: 01/27/2023]
Abstract
Introduction Several studies have reported the presence of electroencephalography (EEG) abnormalities or altered evoked potentials (EPs) during sepsis. However, the role of these tests in the diagnosis and prognostic assessment of sepsis-associated encephalopathy remains unclear. Methods We performed a systematic search for studies evaluating EEG and/or EPs in adult (≥18 years) patients with sepsis-associated encephalopathy. The following outcomes were extracted: a) incidence of EEG/EP abnormalities; b) diagnosis of sepsis-associated delirium or encephalopathy with EEG/EP; c) outcome. Results Among 1976 citations, 17 articles met the inclusion criteria. The incidence of EEG abnormalities during sepsis ranged from 12% to 100% for background abnormality and 6% to 12% for presence of triphasic waves. Two studies found that epileptiform discharges and electrographic seizures were more common in critically ill patients with than without sepsis. In one study, EEG background abnormalities were related to the presence and the severity of encephalopathy. Background slowing or suppression and the presence of triphasic waves were also associated with higher mortality. A few studies demonstrated that quantitative EEG analysis and EP could show significant differences in patients with sepsis compared to controls but their association with encephalopathy and outcome was not evaluated. Conclusions Abnormalities in EEG and EPs are present in the majority of septic patients. There is some evidence to support EEG use in the detection and prognostication of sepsis-associated encephalopathy, but further clinical investigation is needed to confirm this suggestion.
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Affiliation(s)
- Koji Hosokawa
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
| | - Nicolas Gaspard
- Comprehensive Epilepsy Center and Computational Neurophysiology Laboratory, Dept. of Neurology, School of Medicine, Yale University, Yale-New Haven Hospital, New Haven, CT, 06520, USA. .,Department of Neurology, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
| | - Fuhong Su
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
| | - Mauro Oddo
- Department of Intensive Care Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois), Rue du Bugnon 46, 1011, Lausanne, Switzerland.
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
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Abstract
Sepsis associated encephalopathy (SAE) is a common but poorly understood neurological complication of sepsis. It is characterized by diffuse brain dysfunction secondary to infection elsewhere in the body without overt CNS infection. The pathophysiology of SAE is complex and multifactorial including a number of intertwined mechanisms such as vascular damage, endothelial activation, breakdown of the blood brain barrier, altered brain signaling, brain inflammation, and apoptosis. Clinical presentation of SAE may range from mild symptoms such as malaise and concentration deficits to deep coma. The evaluation of cognitive dysfunction is made difficult by the absence of any specific investigations or biomarkers and the common use of sedation in critically ill patients. SAE thus remains diagnosis of exclusion which can only be made after ruling out other causes of altered mentation in a febrile, critically ill patient by appropriate investigations. In spite of high mortality rate, management of SAE is limited to treatment of the underlying infection and symptomatic treatment for delirium and seizures. It is important to be aware of this condition because SAE may present in early stages of sepsis, even before the diagnostic criteria for sepsis can be met. This review discusses the diagnostic approach to patients with SAE along with its epidemiology, pathophysiology, clinical presentation, and differential diagnosis.
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Encéphalopathie associée au sepsis. Rev Neurol (Paris) 2011; 167:195-204. [DOI: 10.1016/j.neurol.2010.07.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2009] [Revised: 04/20/2010] [Accepted: 07/07/2010] [Indexed: 02/05/2023]
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Des pathologies encéphaliques à connaître — L'encéphalopathie associée au sepsis et ses diagnostics différentiels. MEDECINE INTENSIVE REANIMATION 2011. [DOI: 10.1007/s13546-010-0118-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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12
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Checinski A, Polito A, Friedman D, Siami S, Annane D, Sharshar T. Sepsis-associated encephalopathy and its differential diagnosis. FUTURE NEUROLOGY 2010. [DOI: 10.2217/fnl.10.62] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Sepsis-associated encephalopathy (SAE) is defined as a diffuse cerebral dysfunction resulting from the systemic inflammatory response to an infection without direct infestation of the CNS. Although the pathophysiology of SAE is as yet unknown, some mechanisms have been suggested that involve BBB disruption as a consequence of proinflammatory mediators’ effects on endothelial cells. This leads to an increased passage of neurotoxic and proinflammatory mediators into the brain parenchyma, as well as an impairment of the movements of oxygen and metabolites through the BBB. Both neurons and glial cells are affected, resulting in neural functioning and neurotransmission impairment. The clinical translation of this process is an alteration of consciousness and awareness. SAE is a frequent condition in septic patients. Despite being considered reversible, SAE appears to be associated with long-term cognitive impairment. Detection and diagnosis can be challenging; it requires daily neurological assessment with the assistance of clinical scores. Use of biomarkers and neurophysiological testing is discussed. The aim of this article is to provide practical tools for detection of SAE, as well as an updated overview of its pathophysiology and therapeutic perspectives.
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Affiliation(s)
- Anthony Checinski
- General Intensive Care Unit, Raymond Poincaré Teaching Hospital (AP-HP), University of Versailles Saint-Quentin en Yvelines 104, Boulevard Raymond Poincaré, 92380 Garches, France
| | - Andrea Polito
- General Intensive Care Unit, Raymond Poincaré Teaching Hospital (AP-HP), University of Versailles Saint-Quentin en Yvelines 104, Boulevard Raymond Poincaré, 92380 Garches, France
| | - Diane Friedman
- General Intensive Care Unit, Raymond Poincaré Teaching Hospital (AP-HP), University of Versailles Saint-Quentin en Yvelines 104, Boulevard Raymond Poincaré, 92380 Garches, France
| | - Shidasp Siami
- Department of Intensive Care Medicine, Hospital of Sud Essonne, Etampes, France
| | - Djillali Annane
- General Intensive Care Unit, Raymond Poincaré Teaching Hospital (AP-HP), University of Versailles Saint-Quentin en Yvelines 104, Boulevard Raymond Poincaré, 92380 Garches, France
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Szatmári S, Végh T, Antek C, Takács I, Síró P, Fülesdi B. Sepsis-associated encephalopathy. Orv Hetil 2010; 151:1340-6. [DOI: 10.1556/oh.2010.28932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A szepszishez társuló encephalopathia a szisztémás gyulladásos reakció korai szakaszában jelentkező, gyakori, de klinikai szempontból elhanyagolt tünete. A szisztémás szepszis okozta diffúz agyi működészavar, újabb elnevezés szerint a szepszishez társuló encephalopathia (sepsis-associated encephalopathy – SAE) változatos megjelenésű lehet: az átmeneti, reverzíbilis encephalopathiával jellemezhető formától egészen a visszafordíthatatlan agyi károsodással járó súlyos formáig terjedhet a klinikai spektrum. A jelen közleményben a hazai és a nemzetközi szakirodalom áttekintése alapján össze kívántuk foglalni a kórkép kórélettani hátterét, a leggyakrabban előforduló klinikai tüneteket és a kezelés lehetséges módjait. Fel kívántuk hívni a figyelmet arra, hogy szepszisben a különböző súlyosságú tudatzavar az egyik legkorábbi figyelmeztető tünet, ezért a szepszis szempontjából veszélyeztetett betegekben felismerése nagy klinikai jelentőségű.
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Affiliation(s)
- Szilárd Szatmári
- 1 Debreceni Egyetem, Orvos- és Egészségtudományi Centrum Aneszteziológiai és Intenzív Terápiás Tanszék Debrecen Móricz Zs. krt. 22. 4032
| | - Tamás Végh
- 1 Debreceni Egyetem, Orvos- és Egészségtudományi Centrum Aneszteziológiai és Intenzív Terápiás Tanszék Debrecen Móricz Zs. krt. 22. 4032
| | - Csaba Antek
- 1 Debreceni Egyetem, Orvos- és Egészségtudományi Centrum Aneszteziológiai és Intenzív Terápiás Tanszék Debrecen Móricz Zs. krt. 22. 4032
| | - István Takács
- 2 Debreceni Egyetem, Orvos- és Egészségtudományi Centrum Sebészeti Intézet Debrecen
| | - Péter Síró
- 1 Debreceni Egyetem, Orvos- és Egészségtudományi Centrum Aneszteziológiai és Intenzív Terápiás Tanszék Debrecen Móricz Zs. krt. 22. 4032
| | - Béla Fülesdi
- 1 Debreceni Egyetem, Orvos- és Egészségtudományi Centrum Aneszteziológiai és Intenzív Terápiás Tanszék Debrecen Móricz Zs. krt. 22. 4032
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von Haken R, Gruss M, Plaschke K, Scholz M, Engelhardt R, Brobeil A, Martin E, Weigand MA. [Delirium in the intensive care unit]. Anaesthesist 2010; 59:235-47. [PMID: 20127059 DOI: 10.1007/s00101-009-1664-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
In recent years delirium in the intensive care unit (ICU) has internationally become a matter of rising concern for intensive care physicians. Due to the design of highly sophisticated ventilators the practice of deep sedation is nowadays mostly obsolete. To assess a ventilated ICU patient for delirium easy to handle bedside tests have been developed which permit a psychiatric scoring. The significance of ICU delirium is equivalent to organ failure and has been proven to be an independent prognostic factor for mortality and length of ICU and hospital stay. The pathophysiology and risk factors of ICU delirium are still insufficiently understood in detail. A certain constellation of pre-existing patient-related conditions, the current diagnosis and surgical procedure and administered medication entail a higher risk for the occurrence of ICU delirium. A favored hypothesis is that an imbalance of the neurotransmitters acetylcholine and dopamine serotonin results in an unpredictable neurotransmission. Currently, the administration of neuroleptics, enforced physiotherapy, re-orientation measures and appropriate pain treatment are the basis of the therapeutic approach.
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Affiliation(s)
- R von Haken
- Klinik für Anaesthesiologie, Ruprecht-Karls-Universität Heidelberg, Deutschland.
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Abstract
Sepsis is often complicated by an acute and reversible deterioration of mental status, which is associated with increased mortality and is consistent with delirium but can also be revealed by a focal neurologic sign. Sepsis-associated encephalopathy is accompanied by abnormalities of electroencephalogram and somatosensory-evoked potentials, increased in biomarkers of brain injury (i.e., neuron-specific enolase, S-100 beta-protein) and, frequently, by neuroradiological abnormalities, notably leukoencephalopathy. Its mechanism is highly complex, resulting from both inflammatory and noninflammatory processes that affect all brain cells and induce blood-brain barrier breakdown, dysfunction of intracellular metabolism, brain cell death, and brain injuries. Its diagnosis relies essentially on neurologic examination that can lead one to perform specific neurologic tests. Electroencephalography is required in the presence of seizure; neuroimaging in the presence of seizure, focal neurologic signs or suspicion of cerebral infection; and both when encephalopathy remains unexplained. In practice, cerebrospinal fluid analysis should be performed if there is any doubt of meningitis. Hepatic, uremic, or respiratory encephalopathy, metabolic disturbances, drug overdose, withdrawal of sedatives or opioids, alcohol withdrawal delirium, and Wernicke's encephalopathy are the main differential diagnoses of sepsis-associated encephalopathy. Patient management is based mainly on controlling infection, organ system failure, and metabolic homeostasis, at the same time avoiding neurotoxic drugs.
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Abstract
Delirium is a common manifestation of acute brain dysfunction in critically ill patients with prevalence as high as 75%. In the last years there has been a progressive increase of publications regarding intensive care (ICU) delirium, acknowledging its importance. The occurrence of delirium in ICU is related to more adverse outcomes including self-extubation and removal of catheters, prolonged hospitalization, increased costs, higher mortality, and potentially, long-term cognitive impairment. The pathophysiology explaining the processes subtending the development of delirium is still elusive, though several theories have been discussed. It is known that different risk factors are associated with delirium in the ICU. Patients in ICU frequently receive medications to treat pain and to ensure sedation, but an association between these drugs and delirium has been shown. Therefore, this pharmacological exposure should be modified to reduce the risk factors. Giving the multifactorial genesis of delirium, multicomponent interventions to prevent delirium developed in non-ICU settings can be adapted to critically ill patients with the purpose of reducing the incidence. When delirium is diagnosed the use of typical and atypical antipsychotics may be effective for its treatment. Future studies should evaluate target interventions to prevent delirium in the ICU.
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Affiliation(s)
- Alessandro Morandi
- Center for Health Services Research, Vanderbilt Medical Center, Nashville, Tennessee 37232-8300, USA
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Abstract
Brain dysfunction is a severe complication of sepsis with an incidence ranging from 9% to 71% that is associated with increased morbidity and mortality. Its diagnosis relies mainly on neurologic examination with clinical manifestations ranging from confusion to coma. An electroencephalogram, somatosensory evoked potentials, and measurement of plasma S-100b protein and neuron-specific enolase can be useful for the detection of brain dysfunction. Brain MRI can identify brain lesions such as cerebral infarction, posterior reversible encephalopathy syndrome, and leukoencephalopathy. The mechanism of sepsis-associated encephalopathy involves inflammatory and non-inflammatory processes that affect endothelial cells, glial cells, and neurons and induce blood-brain barrier breakdown, derangements of intracellular metabolism, and cell death. Specific treatments for sepsis-associated encephalopathy need to be developed. Currently, treatment is mainly the management of sepsis.
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Bollen PJA, Nielsen BJ, Toft P. Influence of Endotoxin-Induced Sepsis on the Requirements of Propofol-Fentanyl Infusion Rate in Pigs. Basic Clin Pharmacol Toxicol 2007; 101:192-6. [PMID: 17697040 DOI: 10.1111/j.1742-7843.2007.00099.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Endotoxin-induced sepsis in pigs is a recognized experimental model for the study of human septic shock. Generally, pigs are brought into general anaesthesia before sepsis is induced. It is our experience that drug dosages of propofol and fentanyl need to be reduced during endotoxin-induced sepsis, in order to prevent respiratory and cardiovascular depression, but the scientific evidence for this observation is lacking. Therefore, we measured the consumption of propofol and fentanyl at equal level of anaesthesia in pigs with (n = 5) and without (n = 5) endotoxin-induced sepsis, using the cerebral state index (CSI) as measure of anaesthetic depth. Infusion rates of propofol (P < 0.01) and fentanyl (P < 0.05) were significantly lower in septic pigs. Pigs with endotoxin-induced sepsis had an infusion rate of 2.2 mg/kg/hr (S.D. 0.5) for propofol and 12 microg/kg/hr (S.D. 2) for fentanyl, whereas healthy pigs had infusion rates of 3.5 mg/kg/hr (S.D. 0.6) and 17 microg/kg/hr (S.D. 4), respectively. CSI was equal in both groups throughout the experiment, and had a lowest average value of 47 (S.D. 10) at t = 30 in healthy pigs and reached a highest average value of 67 (S.D. 19) at t = 240 in pigs with endotoxin-induced sepsis. Anaesthetic depth was sufficient, assessed clinically, throughout the experiment in both groups. We concluded that the consumption of propofol and fentanyl was significantly reduced in pigs with endotoxin-induced sepsis. In the present study, we adjusted the level of anaesthesia according to clinical signs, and found good agreement with CSI.
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Affiliation(s)
- Peter J A Bollen
- Biomedical Laboratory, University of Southern Denmark, Odense, Denmark.
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Ebersoldt M, Sharshar T, Annane D. Sepsis-associated delirium. Intensive Care Med 2007; 33:941-50. [PMID: 17410344 DOI: 10.1007/s00134-007-0622-2] [Citation(s) in RCA: 179] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2006] [Accepted: 03/06/2007] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Sepsis-associated delirium is a common and poorly understood neurological complication of sepsis. This review provides an update of the diagnostic criteria and treatment strategies and the current knowledge about the mechanisms involved in sepsis associated brain dysfunction. DATA SOURCES Articles published between 1981 and 2006 were identified through a Medline search for "encephalopathy" and "sepsis" and by hand searching of articles cited in the identified publications. The immune response to sepsis results in multiorgan failure including brain dysfunction. DISCUSSION The potential mechanisms for sepsis-associated delirium include vascular damage, endothelial activation, breakdown of the blood-brain barrier, metabolic disorders, brain inflammation and apoptosis. On the other hand, there is evidence for distinct neuroprotective factors, such as anti-inflammatory mediators and glial cell activity. CONCLUSIONS The diagnosis of sepsis-associated delirium relies mainly on clinical and electrophysiological criteria, and its treatment is entirely based on general management of sepsis.
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Affiliation(s)
- Marion Ebersoldt
- Université de Versailles Saint Quentin, Service de Réanimation Médicale, Hôpital Raymond Poincaré (AP-HP), 104 Boulevard Raymond Poincaré, 92380 Garches, France
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Nozari A, Safar P, Wu X, Stezoski WS, Henchir J, Kochanek P, Klain M, Radovsky A, Tisherman SA. Suspended animation can allow survival without brain damage after traumatic exsanguination cardiac arrest of 60 minutes in dogs. ACTA ACUST UNITED AC 2006; 57:1266-75. [PMID: 15625460 DOI: 10.1097/01.ta.0000124268.24159.8b] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We have previously shown in dogs that exsanguination cardiac arrest of up to 120 minutes without trauma under profound hypothermia induced by aortic flush (suspended animation) can be survived without neurologic deficit. In the present study, the effects of major trauma (laparotomy, thoracotomy) are explored. This study is designed to better mimic the clinical scenario of an exsanguinating trauma victim, for whom suspended animation may buy time for resuscitative surgery and delayed resuscitation. METHODS Fourteen dogs were exsanguinated over 5 minutes to cardiac arrest. Flush of saline at 2 degrees C into the femoral artery was initiated at 2 minutes of cardiac arrest and continued until a tympanic temperature of 10 degrees C was achieved. The dogs were then randomized into a control group without trauma (n = 6) or a trauma group (n = 8) that underwent a laparotomy and isolation of the spleen before hemorrhage and then, at the start of cardiac arrest, spleen transection and left thoracotomy. During cardiac arrest, splenectomy was performed. After 60 minutes of no-flow cardiac arrest, reperfusion with cardiopulmonary bypass was followed by intensive care to 72 hours. RESULTS All 14 dogs survived to 72 hours with histologically normal brains. All control dogs were functionally neurologically intact. Four of eight trauma dogs were also functionally normal. Four had neurologic deficits, although three required prolonged mechanical ventilation because of airway edema and evidence of multiple organ failure. Blood loss from the chest and abdomen was variable and was associated with poor functional outcomes. CONCLUSION Rapid induction of profound hypothermic suspended animation (tympanic temperature, 10 degrees C) can enable survival without brain damage after exsanguination cardiac arrest of 60 minutes even in the presence of trauma, although prolonged intensive care may be required. This technique may allow survival of exsanguinated trauma victims, who now have almost no chance of survival.
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Affiliation(s)
- Ala Nozari
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Müller-Werdan U, Buerke M, Christoph A, Flieger R, Loppnow H, Prondzinsky R, Reith S, Schmidt H, Werdan K. Schock. KLINISCHE KARDIOLOGIE 2006. [PMCID: PMC7143837 DOI: 10.1007/3-540-29425-2_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
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Jaber S, Chanques G, Altairac C, Sebbane M, Vergne C, Perrigault PF, Eledjam JJ. A prospective study of agitation in a medical-surgical ICU: incidence, risk factors, and outcomes. Chest 2005; 128:2749-57. [PMID: 16236951 DOI: 10.1378/chest.128.4.2749] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
STUDY OBJECTIVES Although agitation is thought to be common in the ICU, it has been poorly studied. We evaluated the incidence, risks factors, and outcomes of agitation in ICU. DESIGN Prospective observational study. INTERVENTIONS None. METHOD All consecutive ICU admissions over an 8-month period were analyzed. MEASUREMENTS AND RESULTS Two hundred eleven patients were admitted a total of 216 times during the period of the study. Twenty-nine patients were excluded from the study because their pathology findings did not allow an evaluation of their level of consciousness; 182 patients were actually enrolled. Agitation developed in 95 of 182 patients (52%). Agitation began 4.4 +/- 5.6 days (+/- SD) after admission to the ICU and lasted 3.9 +/- 4.1 days. Patients with agitation had a higher Simplified Acute Physiology Score II on ICU admission than those who did not have agitation (40 +/- 16 vs 33 +/- 13, p < 0.01). By stepwise logistic regression, the independent risks factors for development of agitation included psychoactive drug use at the time of ICU admission (odds ratio, 5.63; 95% confidence interval [CI], 1.32 to 23.70), history of alcohol abuse (odds ratio, 3.32; 95% CI, 1.12 to 10.00), dysnatremia (odds ratio, 4.95; 95% CI, 1.95 to 12.54), fever (odds ratio, 4.52; 95% CI, 1.80 to 11.49), use of sedatives in the ICU (odds ratio, 4.03; 95% CI, 1.62 to 10.40), and sepsis (odds ratio, 2.61; 95% CI, 1.03 to 6.58). Agitation was associated with a prolonged ICU stay (16 +/- 19 days vs 6 +/- 6 days, p = 0.0001), nosocomial infections (34% vs 7%, p < 0.0001), unplanned extubations (17% vs 2%, p = 0.003), and unplanned central venous catheter removal (16% vs 1%, p = 0.001), but not with mortality (12% in the agitation group vs 8% in patients without agitation). CONCLUSIONS Agitation is a common event in a mixed medical-surgical ICU. It is associated with adverse outcomes including prolonged stay, nosocomial infections, and unplanned extubations. A better knowledge of incidence and risk factors should facilitate identification of patients at risk and decrease the incidence of agitation.
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Affiliation(s)
- Samir Jaber
- Intensive Care Unit and Transplantation, Department of Anesthesiology, DAR B, Hospital Saint Eloi, University of Montpellier, Montpellier Cedex 5, France.
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Abstract
On one side, brain dysfunction is a poorly explored complication of sepsis. On the other side, brain dysfunction may actively contribute to the pathogenesis of sepsis. The current review aimed at summarizing the current knowledge about the reciprocal interaction between the immune and central nervous systems during sepsis. The immune-brain cross talk takes part in circumventricular organs that, being free from blood-brain-barrier, interface between brain and bloodstream, in autonomic nuclei including the vagus nerve, and finally through the damaged endothelium. Recent observations have confirmed that sepsis is associated with excessive brain inflammation and neuronal apoptosis which clinical relevance remains to be explored. In parallel, damage within autonomic nervous and neuroendocrine systems may contribute to sepsis induced organ dysfunction.
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Affiliation(s)
- Tarek Sharshar
- Attending Physician, Service de Réanimation Médicale, Hôpital Raymond Poincaré, Faculté de Médecine Paris Ile de France Ouest, Université de Versailles Saint-Quentin-en-Yvelines, Garches, France
| | - Nicholas S Hopkinson
- Attending Physician, Respiratory Muscle Laboratory, Royal Brompton and Harefield NHS Trust, Fulham Road, London, SW3 6NP, United Kingdom
| | - David Orlikowski
- Attending Physician, Service de Réanimation Médicale, Hôpital Raymond Poincaré, Faculté de Médecine Paris Ile de France Ouest, Université de Versailles Saint-Quentin-en-Yvelines, Garches, France
| | - Djillali Annane
- Head of ICU Department, Service de Réanimation Médicale, Hôpital Raymond Poincaré, Faculté de Médecine Paris Ile de France Ouest, Université de Versailles Saint-Quentin-en-Yvelines, Garches, France
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Walsh TS, Ramsay P, Kinnunen R. Monitoring sedation in the intensive care unit: can "black boxes" help us? Intensive Care Med 2004; 30:1511-3. [PMID: 15057513 DOI: 10.1007/s00134-004-2271-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2004] [Indexed: 01/05/2023]
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Sharshar T, Annane D, de la Gradmaison GL, Brouland JP, Hopkinson NS, Gray F. The neuropathology of septic shock. Brain Pathol 2004; 14:21-33. [PMID: 14997934 PMCID: PMC8095740 DOI: 10.1111/j.1750-3639.2004.tb00494.x] [Citation(s) in RCA: 226] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The neuropathological correlates of encephalopathy and autonomic dysfunction in septic shock are unclear. We performed post mortem analysis of 5 brain areas susceptible to ischemia and 5 autonomic nuclei (AN) in 23 patients who had died in our intensive care unit (ICU) from septic shock and 8 dying from non-septic shock as well as 5 controls who had died suddenly from extracranial injury. Proinflammatory cytokine (IL1-beta and TNF-alpha) and inducible nitric oxide synthase (iNOS) expression was assessed by immunocytochemistry. Abnormalities in septic shock were: hemorrhages (26%), hypercoagulability syndrome (9%), micro-abscesses (9%), multifocal necrotizing leukoencephalopathy (9%) and ischemia (100%). The incidence of cerebral hemorrhage or hypercoagulability syndrome was not related to clotting disturbances. The intensity of ischemia within susceptible areas was the same in both ICU groups, but more pronounced in the autonomic centers of septic patients (P < 0.0001). Neuronal apoptosis assessed using anti-caspase 3 immunocytochemistry and in situ end labeling was more pronounced in the autonomic nuclei of septic patients. (P < 0.0001). TNF-alpha expression did not differ between groups but vascular iNOS expression assessed by immunocytochemistry was higher in sepsis (P<0.0001) and correlated with autonomic center neuronal apoptosis (P < 0.02). We conclude that septic shock is associated with diffuse cerebral damage and specific autonomic neuronal apoptosis which may be due to circulating factors particularly iNOS.
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Affiliation(s)
- Tarek Sharshar
- Service de Réanimation Médicale, Hôpital Raymond Poincaré, Faculté de Médecine paris‐Ile de France Ouest, Garches, France
- National Heart and Lung Institute, Royal Brompton Hospital, united Kingdom
| | - Djillali Annane
- Service de Réanimation Médicale, Hôpital Raymond Poincaré, Faculté de Médecine paris‐Ile de France Ouest, Garches, France
| | - Geoffroy Lorin de la Gradmaison
- Service d'Anatomo‐Pathologie et de Médecine Légale, Hôpital Rayemond poincaré Faculté de Médecine paris‐Ile de France Ouest, Garches, France
| | - Jean Philippe Brouland
- Service d'Anatomo‐Pathologie et de Médecine Légale, Hôpital Rayemond poincaré Faculté de Médecine paris‐Ile de France Ouest, Garches, France
| | | | - Françoise Gray
- Service d'Anatomo‐Pathologie et de Médecine Légale, Hôpital Rayemond poincaré Faculté de Médecine paris‐Ile de France Ouest, Garches, France
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Ohnesorge H, Bischoff P, Scholz J, Yekebas E, Schulte am Esch J. Somatosensory evoked potentials as predictor of systemic inflammatory response syndrome in pigs? Intensive Care Med 2003; 29:801-7. [PMID: 12577145 DOI: 10.1007/s00134-003-1657-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2002] [Accepted: 12/20/2002] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Sepsis or systemic inflammatory response syndrome (SIRS) is often associated with encephalopathy (70%), which has been described as an early symptom resulting in several diseases. The present study investigated somatosensory evoked potentials (SEP) as an indicator or even a predictor of cerebral dysfunction evaluated in an experimental model of SIRS in pigs. METHODS Eight Göttinger minipigs were included in the study. SIRS was mediated by induction of pancreatitis due to injection (ductus pancreaticus) of 500 mg/kg sodium taurocholate and 2.5 IU/kg enterokinase. Monitored parameters were: arterial blood-central venous-pulmonary arterial pressure, and cardiac output, systemic vascular resistance, and body temperature. SEP were recorded from centroparietal vs. frontal areas after electrical stimulation of the right forepaw. RESULTS At least 33% loss of vascular resistance from baseline (SIRS criteria) occurred in all animals within 4-18 h. Baseline recordings in all anesthetized animals indicated primary cortical responses to electrical stimuli identified by peak latencies between 15-20 ms (SEP(P15-20)). Attenuations in the amplitudes with significant median decreases of 46% were observed at least 4 h before the defined hemodynamic SIRS criteria. CONCLUSIONS The present data show a trend for the attenuation in SEP amplitudes as an indicator of systemic inflammatory response. SEP monitoring may be a sensitive marker of developing early changes in cerebral function due to SIRS-related encephalopathy.
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Affiliation(s)
- Henning Ohnesorge
- Department of Anesthesiology, University Hospital Hamburg Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
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27
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Zumsteg D, Wieser HG. Effects of aging and sex on middle-latency somatosensory evoked potentials: normative data. Clin Neurophysiol 2002; 113:681-5. [PMID: 11976047 DOI: 10.1016/s1388-2457(02)00054-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To investigate the exact relationship of middle-latency somatosensory evoked potential (SEP) components (in particular the third negative component N60) to age and sex in a normal population. Middle-latency SEPs are believed to show a considerable inter-individual variability and there is little published information on normative data of these components. METHODS Eighty-three healthy subjects aged 13-80 years were investigated using a standard SEP procedure. RESULTS Both latency and amplitude of N60 increased substantially with age. Least square polynomial regression analysis showed that a quadratic curve best described its relationship (r2=0.67 for the latency, r2=0.18 for the amplitude). Data did not differ significantly with reference to sex or side of stimulation. CONCLUSIONS The use of polynomial regression analysis for the determination of the normal range of N60 latencies and amplitudes has to be highly recommended. It might improve the accuracy with which abnormal results are detected in studies investigating the value of middle-latency SEPs in various diseases.
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Affiliation(s)
- Dominik Zumsteg
- Department of Neurology, University Hospital Zurich, Frauenklinikstrasse 26, Switzerland.
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Zauner C, Gendo A, Kramer L, Funk GC, Bauer E, Schenk P, Ratheiser K, Madl C. Impaired subcortical and cortical sensory evoked potential pathways in septic patients. Crit Care Med 2002; 30:1136-9. [PMID: 12006815 DOI: 10.1097/00003246-200205000-00030] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Sensory evoked potential (SEP) peak latencies were recorded in order to evaluate the incidence and severity of septic encephalopathy, testing the hypothesis that the occurrence of septic encephalopathy is more frequent than generally assumed. DESIGN Prospective cohort study. SETTING Medical intensive care unit of a university hospital. PATIENTS Sixty-eight critically ill patients were studied within 48 hrs after the development of severe sepsis (n = 41) or septic shock (n = 27). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Septic encephalopathy was defined as prolongation of SEP peak latencies beyond the upper limit of the reference range of subcortical (N13-N20 interpeak latency) and cortical SEP pathways (N20-N70 interpeak latency), as well as asymmetry of peak latencies marked by the presence of subclinical cerebral focal signs. Subcortical SEP pathways were impaired in 34% and cortical SEP pathways in 84% of all patients. The prolongation of the cortical SEP pathway correlated with the Acute Physiology and Chronic Health Evaluation III score (r = 0.23; p <.0001). SEP peak latencies did not differ in patients with severe sepsis compared with those with septic shock. Subclinical cerebral focal signs were present in 24% of the subcortical SEP pathways and in 6% of the cortical SEP pathways. CONCLUSIONS Septic encephalopathy occurs more frequently than generally assumed, and its severity is associated with the severity of illness. The impairment of subcortical and cortical SEP pathways was not different between patients with severe sepsis and those with septic shock.
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Affiliation(s)
- Christian Zauner
- Department of Internal Medicine IV, Intensive Care Unit, University of Vienna, Vienna, Austria.
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Floyd TF, Cheung AT, Stecker MM. Postoperative neurologic assessment and management of the cardiac surgical patient. Semin Thorac Cardiovasc Surg 2000; 12:337-48. [PMID: 11154729 DOI: 10.1053/stcs.2000.20040] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The neurologic evaluation of patients in the immediate postoperative period and postanesthetic state is unique and challenging. Neurologic assessment is complicated by the lingering residual effects of anesthetics as well as by the effects of narcotic analgesics, anxiolytics, and muscle relaxants, especially in ventilated patients. In this review we examine the suspected causes, clinical manifestations, diagnostic options, and intervention schemes for the common neurologic syndromes seen after cardiac operations.
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Affiliation(s)
- T F Floyd
- Department of Anesthesia, University of Pennsylvania, Philadelphia, PA 19104-4283, USA
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