Acute brain failure in severe sepsis: a prospective study in the medical intensive care unit utilizing continuous EEG monitoring
Acute brain failure in severe sepsis: a prospective study in the medical intensive care unit utilizing continuous EEG monitoring
复制标题
DOI：
10.1007/s00134-015-3709-1
复制
发表时间：
2015-04-01
影响因子：
38.9
通讯作者：
Hirsch, Lawrence J.
中科院分区：
文献类型：
--
作者：
Gilmore, Emily J.;Gaspard, Nicolas;Hirsch, Lawrence J.
对某学术中心内科ICU连续收治的严重脓毒症患者进行前瞻性、单中心、观察性研究。共纳入98例100次严重脓毒症患者，其中女性49例(50%)，年龄中位数60岁(IQR 52~74)，非神经性APACHE II评分中位数23.5(IQR 18~28)，非神经性SOFA评分中位数8(IQR 6~11)。25例有周期性放电(PD)，其中11例有非惊厥发作(NCS)。无一例无PD的NCS患者。既往神经病史与PD或NCS的风险较高(45vs.17%；CI 1.53~10.43)，而非APACHE II、非神经沙发、心血管休克的严重程度和cEEG期间镇静的存在与PD或NCS的风险较低相关。CEEG前的临床发作与非惊厥性癫痫持续状态的风险较高(24比6%；CI 1.42~19.94)，而非神经性APACHE II评分和非神经性SOFA评分与较低的风险相关。28%的患者出现脑电反应性不足。在生存分析中，缺乏脑电反应与较高的1年死亡率[平均生存时间3.3(95%CI1.8-4.9)vs.7.5(6.4-8.7)个月；p=0.002]但PD或NCS的存在并不[平均生存时间3.3(95%CI1.8-4.9)vs.7.5(6.4-8.7)个月；p=0.592]。在持续镇静的cEEG患者中，缺乏反应性的情况更常见。在有1年资料的患者中(34%的发作)，82%的患者有良好的功能结果(MRS a Parts PERS PERS 3，n=27)。没有显著的预测功能结果、认知迟缓的指标，也没有获得完整随访数据的患者出现迟发性癫痫或新的癫痫。NCS和PD在严重脓毒症和精神状态改变的患者中很常见。在病情最严重的患者中，它们的发生率较低，并且与本研究的结果无关。脑电反应性缺乏在持续镇静的患者中更为常见，并与出院后1年内的死亡率有关。要在更广泛的人群中证实这些发现，并进一步评估长期认知结果、晚期癫痫发作和癫痫的风险，还需要进行更大规模的研究。
Investigate the prevalence, risk factors and impact of continuous EEG (cEEG) abnormalities on mortality through the 1-year follow-up period in patients with severe sepsis.Prospective, single-center, observational study of consecutive patients admitted with severe sepsis to the Medical ICU at an academic medical center.A total of 98 patients with 100 episodes of severe sepsis were included; 49 patients (50%) were female, median age was 60 (IQR 52-74), the median non-neuro APACHE II score was 23.5 (IQR 18-28) and median non-neuro SOFA score was 8 (IQR 6-11). Twenty-five episodes had periodic discharges (PD), of which 11 had nonconvulsive seizures (NCS). No patient had NCS without PD. Prior neurological history was associated with a higher risk of PD or NCS (45 vs. 17%; CI 1.53-10.43), while the non-neuro APACHE II, non-neuro SOFA, severity of cardiovascular shock and presence of sedation during cEEG were associated with a lower risk of PD or NCS. Clinical seizures before cEEG were associated with a higher risk of nonconvulsive status epilepticus (24 vs. 6%; CI 1.42-19.94) while the non-neuro APACHE II and non-neuro SOFA scores were associated with a lower risk. Lack of EEG reactivity was present in 28% of episodes. In the survival analysis, a lack of EEG reactivity was associated with higher 1-year mortality [mean survival time 3.3 (95% CI 1.8-4.9) vs. 7.5 (6.4-8.7) months; p = 0.002] but the presence of PD or NCS was not [mean survival time 3.3 (95% CI 1.8-4.9) vs. 7.5 (6.4-8.7) months; p = 0.592]. Lack of reactivity was more frequent in patients on continuous sedation during cEEG. In patients with available 1-year data (34% of the episodes), 82% had good functional outcome (mRS a parts per thousand currency sign 3, n = 27). There were no significant predictors of functional outcome, late cognition, and no patient with complete follow-up data developed late seizure or new epilepsy.NCS and PD are common in patients with severe sepsis and altered mental status. They were less frequent among the most severely sick patients and were not associated with outcome in this study. Lack of EEG reactivity was more frequent in patients on continuous sedation and was associated with mortality up to 1 year after discharge. Larger studies are needed to confirm these findings in a broader population and to further evaluate long-term cognitive outcome, risk of late seizure and epilepsy.