title: Brainstem responses can predict death and delirium in sedated patients in intensive care unit.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  Observational prospective study including an initial single-center and a subsequent multicenter study to develop and then validate the prognostic models.
  
  
  METHODS
  Three mixed and two medical intensive care units.
  
  
  METHODS
  Mechanically ventilated intensive care unit patients sedated with midazolam (± sufentanyl).
  
  
  METHODS
  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.
  
  
  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.
authors.affiliation: General Intensive Care Unit, University of Versailles Saint-Quentin en Yvelines, Garches, France. tarek.sharshar@rpc.aphp.fr
authors.forename: Tarek
authors.initials: T
authors.lastname: Sharshar
authors.forename: Raphaël
authors.initials: R
authors.lastname: Porcher
authors.forename: Shidasp
authors.initials: S
authors.lastname: Siami
authors.forename: Benjamim
authors.initials: B
authors.lastname: Rohaut
authors.forename: Juliette
authors.initials: J
authors.lastname: Bailly-Salin
authors.forename: Nicholas S
authors.initials: NS
authors.lastname: Hopkinson
authors.forename: Bernard
authors.initials: B
authors.lastname: Clair
authors.forename: Celine
authors.initials: C
authors.lastname: Guidoux
authors.forename: Emanuele
authors.initials: E
authors.lastname: Iacobone
authors.forename: Romain
authors.initials: R
authors.lastname: Sonneville
authors.forename: Andrea
authors.initials: A
authors.lastname: Polito
authors.forename: Jerome
authors.initials: J
authors.lastname: Aboab
authors.forename: Stephane
authors.initials: S
authors.lastname: Gaudry
authors.forename: Olivier
authors.initials: O
authors.lastname: Morla
authors.forename: Grégory
authors.initials: G
authors.lastname: Amouyal
authors.forename: Julien
authors.initials: J
authors.lastname: Azuar
authors.forename: Jérémy
authors.initials: J
authors.lastname: Allary
authors.forename: Antoine
authors.initials: A
authors.lastname: Vieillard-Baron
authors.forename: Michel
authors.initials: M
authors.lastname: Wolff
authors.forename: Alain
authors.initials: A
authors.lastname: Cariou
authors.forename: Djillali
authors.initials: D
authors.lastname: Annane
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002423:Cause of Death; D015331:Cohort Studies; D016292:Procedural Sedation / Q000009:adverse effects / Q000379:methods*; D003422:Critical Care / Q000379:methods; D016638:Critical Illness / Q000401:mortality* / Q000628:therapy; D003693:Delirium / Q000188:drug therapy / Q000401:mortality*; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D016057:Evoked Potentials, Auditory, Brain Stem / Q000502:physiology*; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage* / Q000009:adverse effects; D007262:Infusions, Intravenous; D007362:Intensive Care Units; D016015:Logistic Models; D008297:Male; D001523:Mental Disorders / Q000175:diagnosis / Q000401:mortality; D008874:Midazolam / Q000008:administration & dosage / Q000009:adverse effects; D008875:Middle Aged; D015999:Multivariate Analysis; D009460:Neurologic Examination / Q000379:methods; D011237:Predictive Value of Tests; D011446:Prospective Studies; D017409:Sufentanil / Q000008:administration & dosage / Q000009:adverse effects; D016019:Survival Analysis
chemical_list: D006993:Hypnotics and Sedatives; D017409:Sufentanil; D008874:Midazolam