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

Benjamin Rohaut, Raphael Porcher, Tarik Hissem, Nicholas Heming, Patrick Chillet, Kamel Djedaini, Guy Moneger, Stanislas Kandelman, Jeremy Allary, Alain Cariou, Romain Sonneville, Andréa Polito, Marion Antona, Eric Azabou, Djillali Annane, Shidasp Siami, Fabrice Chrétien, Jean Mantz, Tarek Sharshar, Groupe d’Exploration Neurologique en Réanimation (GENER), Benjamin Rohaut, Raphael Porcher, Tarik Hissem, Nicholas Heming, Patrick Chillet, Kamel Djedaini, Guy Moneger, Stanislas Kandelman, Jeremy Allary, Alain Cariou, Romain Sonneville, Andréa Polito, Marion Antona, Eric Azabou, Djillali Annane, Shidasp Siami, Fabrice Chrétien, Jean Mantz, Tarek Sharshar, Groupe d’Exploration Neurologique en Réanimation (GENER)

Abstract

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.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1. Flow chart.
Fig 1. Flow chart.
NMBA: neuromuscular-blocking agent; RASS: Richmond Assessment Sedation Scale.
Fig 2. Representation of homogeneous and heterogeneous…
Fig 2. Representation of homogeneous and heterogeneous profiles.
The percentage of abolition of each tested neurological responses in homogeneous and heterogeneous profiles are depicted. The heterogeneous profile is characterized by a greater and more heterogeneous abolition of neurological responses.
Fig 3. 28-day mortality probability according to…
Fig 3. 28-day mortality probability according to the BRASS.
Mortality probability expressed in mean [95%CI], BRASS: Brainstem Responses Assessment Sedation Score.

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