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EARLY ABOLITION OF COUGH REFLEX PREDICTS MORTALITY IN DEEPLY SEDATED BRAIN-INJURED PATIENTS
Kandelman, Stanislas et al. | Date Issued: 2020
Author
Kandelman, Stanislas
Allary, Jérémy
Porcher, Raphael
Righy, Cássia
Valdez, Clarissa Francisca
Rasulo, Frank
Heming, Nicholas
Moneger, Guy
Azabou, Eric
Savary, Guillaume
Annane, Djillali
Chretien, Fabrice
Latronico, Nicola
Bozza, Fernando A.
Rohaut, Benjamin
Sharshar, Tarek
Affilliation
University Denis Diderot. Beaujon Hospital. Department of Anesthesiology and Intensive Care Unit. Clichy, France / McGill University Health Center. Royal Victoria Hospital. Department of Anesthesia. Montréal, QC, Canada.
University Denis Diderot. Beaujon Hospital. Department of Anesthesiology and Intensive Care Unit. Clichy, France.
University Paris Descartes. Hotel Dieu Hospital. Assistance Publique Hôpitaux de Paris. Center for Clinical Epidemiology. Paris, France.
Fundação Oswaldo Cruz. Instituto Nacional de Infectologia Evandro Chagas. Rio de Janeiro, RJ, Brasil / Instituto Estadual do Cérebro Paulo Niemeyer. Unidade de Tratamento Intensivo. Rio de Janeiro, RJ, Brasil.
Instituto Estadual do Cérebro Paulo Niemeyer. Unidade de Tratamento Intensivo. Rio de Janeiro, RJ, Brasil / Hospital das Américas. Unidade de Tratamento Intensivo. Rio de Janeiro, RJ, Brasil.
Spedali Civili University Hospital. Department of Anesthesia. Critical Care and Emergency. Brescia, Italy / University of Brescia. Radiological Sciences and Public Health. Department of Medical and Surgical Specialties. Brescia, Italy.
University of Versailles Saint-Quentin en Yvelines. Raymond-Poincaré Hospital. Assistance Publique Hôpitaux de Paris. General Intensive Care Unit. Garches, France.
University of Versailles Saint-Quentin en Yvelines. Raymond-Poincaré Hospital. Assistance Publique Hôpitaux de Paris. General Intensive Care Unit. Garches, France.
University of Versailles Saint-Quentin en Yvelines. Raymond-Poincaré Hospital. Assistance Publique Hôpitaux de Paris. Department of Physiology. Garches, France.
University Denis Diderot. Beaujon Hospital. Department of Anesthesiology and Intensive Care Unit. Clichy, France.
University of Versailles Saint-Quentin en Yvelines. Raymond-Poincaré Hospital. Assistance Publique Hôpitaux de Paris. General Intensive Care Unit. Garches, France.
Institut Pasteur. Laboratory of Human Histopathology and Animal Models. Paris, France.
Spedali Civili University Hospital. Department of Anesthesia, Critical Care and Emergency. Brescia, Italy / University of Brescia. Radiological Sciences and Public Health. Department of Medical and Surgical Specialties. Brescia, Italy.
Fundação Oswaldo Cruz. Instituto Nacional de Infectologia Evandro Chagas. Rio de Janeiro, RJ, Brasil / Instituto D'Or de Pesquisa e Educação. Rio de Janeiro, RJ, Brasil.
Groupe Hospitalier Pitié-Salpêtrière. Intensive Care Unit. Department of Neurology. Paris, France / Sorbonne Universités. Faculté de Médecine Pitié-Salpêtrière. Paris, France / Columbia University. Critical Care Neurology. Department of Neurology. New York, NY, USA.
Institut Pasteur. Laboratory of Human Histopathology and Animal Models. Paris, France / Instituto D'Or de Pesquisa e Educação. Rio de Janeiro, RJ, Brasil / University of Paris-Descartes. Sainte-Anne Teaching Hospital. Neuro-Anesthesiology and Intensive Care Unit. Paris, France.
Abstract
Background: Deep sedation may hamper the detection of neurological deterioration in brain-injured patients. Impaired brainstem reflexes within the first 24 h of deep sedation are associated with increased mortality in non-brain-injured patients. Our objective was to confirm this association in brain-injured patients. Methods: This was an observational prospective multicenter cohort study involving four neuro-intensive care units. We included acute brain-injured patients requiring deep sedation, defined by a Richmond Assessment Sedation Scale (RASS) < -3. Neurological assessment was performed at day 1 and included pupillary diameter, pupillary light, corneal and cough reflexes, and grimace and motor response to noxious stimuli. Pre-sedation Glasgow Coma Scale (GCS) and Simplified Acute Physiology Score (SAPS-II) were collected, as well as the cause of death in the Intensive Care Unit (ICU). Results: A total of 137 brain-injured patients were recruited, including 70 (51%) traumatic brain-injured patients, 40 (29%) vascular (subarachnoid hemorrhage or intracerebral hemorrhage). Thirty patients (22%) died in the ICU. At day 1, the corneal (OR 2.69, p = 0.034) and cough reflexes (OR 5.12, p = 0.0003) were more frequently abolished in patients that died in the ICU. In a multivariate analysis, abolished cough reflex was associated with ICU mortality after adjustment to pre-sedation GCS, SAPS-II, RASS (OR: 5.19, 95% CI [1.92-14.1], p = 0.001) or dose of sedatives (OR: 8.89, 95% CI [2.64-30.0], p = 0.0004). Conclusion: Early (day 1) cough reflex abolition is an independent predictor of mortality in deeply sedated brain-injured patients. Abolished cough reflex likely reflects a brainstem dysfunction that might result from the combination of primary and secondary neuro-inflammatory cerebral insults revealed and/or worsened by sedation.
Keywords
Brain injury
Brainstem dysfunction
Cough reflex
Critical care
Deep sedation
Neurological examination
Neuroprognosis
 
Publisher
PeerJ
Citation
KANDELMAN, Stanislas et al. Early abolition of cough reflex predicts mortality in deeply sedated brain-injured patients. PeerJ, v. 8, p. 1-16, Nov. 2020.
DOI
10.7717/peerj.10326
ISSN
2167-8359