Brainstem response patterns in deeply-sedated critically-ill patients predict 28-day mortalityReport as inadecuate

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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.


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.


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.


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.

Author: Benjamin Rohaut, Raphael Porcher, Tarik Hissem, Nicholas Heming, Patrick Chillet, Kamel Djedaini, Guy Moneger, Stanislas Kandelma



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