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01-08-2018 | Original Article

Duration of Agitation, Fluctuations of Consciousness, and Associations with Outcome in Patients with Subarachnoid Hemorrhage

Authors: Michael E. Reznik, Ali Mahta, J. Michael Schmidt, Hans-Peter Frey, Soojin Park, David J. Roh, Sachin Agarwal, Jan Claassen

Published in: Neurocritical Care | Issue 1/2018

Abstract

Background

Agitation is common after subarachnoid hemorrhage (SAH) and may be independently associated with outcomes. We sought to determine whether the duration of agitation and fluctuating consciousness were also associated with outcomes in patients with SAH.

Methods

We identified all patients with positive Richmond Agitation Sedation Scale (RASS) scores from a prospective observational cohort of patients with SAH from 2011 to 2015. Total duration of agitation was extrapolated for each patient using available RASS scores, and 24-h mean and standard deviation (SD) of RASS scores were calculated for each patient. We also calculated each patient’s duration of substantial fluctuation of consciousness, defined as the number of days with 24-h RASS SD > 1. Patients were stratified by 3-month outcome using the modified Rankin scale, and associations with outcome were assessed via logistic regression.

Results

There were 98 patients with at least one positive RASS score, with median total duration of agitation 8 h (interquartile range [IQR] 4–18), and median duration of substantially fluctuating consciousness 2 days (IQR 1–3). Unfavorable 3-month outcome was significantly associated with a longer duration of fluctuating consciousness (odds ratio [OR] per day, 1.51; 95% confidence interval [CI], 1.04–2.20; p = 0.031), but a briefer duration of agitation (OR per hour, 0.94; 95% CI, 0.89–0.99; p = 0.031).

Conclusion

Though a longer duration of fluctuating consciousness was associated with worse outcomes in our cohort, total duration of agitation was not, and may have had the opposite effect. Our findings should therefore challenge the intensity with which agitation is often treated in SAH patients.

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Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM, Coursin DB, Herr DL, Tung A, Robinson BRH, Fontaine DK, Ramsay MA, Riker RR, Sessler CN, Pun B, Skrobik Y, Jaeschke R. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263–306. https://doi.org/10.1097/CCM.0b013e3182783b72.CrossRefPubMed

Reznik ME, Schmidt JM, Mahta A, Agarwal S, Roh DJ, Park S, Frey HP, Claassen J. Agitation after subarachnoid hemorrhage: a frequent omen of hospital complications associated with worse outcomes. Neurocrit Care. 2017;26(3):428–435. https://doi.org/10.1007/s12028-016-0331-1.CrossRefPubMedPubMedCentral

Bogner J, Barrett RS, Hammond FM, Horn SD, Corrigan JD, Rosenthal J, Beaulieu CL, Waszkiewicz M, Shea T, Reddin CJ, Cullen N, Giuffrida CG, Young J, Garmoe W. Predictors of agitated behavior during inpatient rehabilitation for traumatic brain injury. Arch Phys Med Rehabil. 2015;96(8, Supplement):S274–S281.e274. https://doi.org/10.1016/j.apmr.2015.04.020.CrossRefPubMed

Singh R, Venkateshwara G, Nair KPS, Khan M, Saad R. Agitation after traumatic brain injury and predictors of outcome. Brain Inj. 2014;28(3):336–40. https://doi.org/10.3109/02699052.2013.873142.CrossRefPubMed

Nott MT, Chapparo C, Baguley IJ. Agitation following traumatic brain injury: an Australian sample. Brain Inj. 2006;20(11):1175–82. https://doi.org/10.1080/02699050601049114.CrossRefPubMed

Caeiro L, Ferro JM, Albuquerque R, Figueira ML. Delirium in the first days of acute stroke. J Neurol. 2004;251(2):171–8. https://doi.org/10.1007/s00415-004-0294-6.CrossRefPubMed

Oldenbeuving AW, de Kort PLM, Jansen BPW, Algra A, Kappelle LJ, Roks G. Delirium in the acute phase after stroke: incidence, risk factors, and outcome. Neurology. 2011;76(11):993–9. https://doi.org/10.1212/WNL.0b013e318210411f.CrossRefPubMed

van der Mast RC, Fekkes D. Serotonin and amino acids: partners in delirium pathophysiology? Semin Clin Neuropsychiatry. 2000;5(2):125–31.PubMed

Hshieh TT, Fong TG, Marcantonio ER, Inouye SK. Cholinergic deficiency hypothesis in delirium: a synthesis of current evidence. J Gerontol Ser A Biol Sci Med Sci. 2008;63(7):764–72.CrossRef

10.

Maldonado JR. Pathoetiological model of delirium: a comprehensive understanding of the neurobiology of delirium and an evidence-based approach to prevention and treatment. Crit Care Clin. 2008;24(4):789–856. https://doi.org/10.1016/j.ccc.2008.06.004.CrossRefPubMed

11.

Ali S, Patel M, Jabeen S, Bailey RK, Patel T, Shahid M, Riley WJ, Arain A. Insight into delirium. Innov Clin Neurosci. 2011;8(10):25–34.PubMedPubMedCentral

12.

Robinson TN, Raeburn CD, Angles EM, Moss M. Low tryptophan levels are associated with post-operative delirium in the elderly. Am J Surg. 2008;196(5):670–4. https://doi.org/10.1016/j.amjsurg.2008.07.007.CrossRefPubMedPubMedCentral

13.

Goldstein LB. Neurotransmitters and motor activity: effects on functional recovery after brain injury. NeuroRx. 2006;3(4):451–7. https://doi.org/10.1016/j.nurx.2006.07.010.CrossRefPubMedPubMedCentral

14.

Chollet F, Tardy J, Albucher J-F, Thalamas C, Berard E, Lamy C, Bejot Y, Deltour S, Jaillard A, Niclot P, Guillon B, Moulin T, Marque P, Pariente J, Arnaud C, Loubinoux I. Fluoxetine for motor recovery after acute ischemic stroke (FLAME): a randomised placebo-controlled trial. Lancet Neurol. 2011;10(2):123–30. https://doi.org/10.1016/S1474-4422(10)70314-8.CrossRefPubMed

15.

Feeney D, Gonzalez A, Law W. Amphetamine, haloperidol, and experience interact to affect rate of recovery after motor cortex injury. Science. 1982;217(4562):855–7. https://doi.org/10.1126/science.7100929.CrossRefPubMed

16.

Goldstein LB, Bullman S. Differential effects of haloperidol and clozapine on motor recovery after sensorimotor cortex injury in rats. Neurorehabilitation Neural Repair. 2002;16(4):321–5. https://doi.org/10.1177/154596830201600402.CrossRefPubMed

17.

Bogner JA, Corrigan JD, Fugate L, Mysiw WJ, Clinchot D. Role of agitation in prediction of outcomes after traumatic brain injury. Am J Phys Med Rehabil. 2001;80(9):636–44.CrossRefPubMed

18.

Connolly ES, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American heart association/American stroke association. Stroke. 2012;. https://doi.org/10.1161/STR.0b013e3182587839.CrossRefPubMedPubMedCentral

19.

Hunt William E, Hess Robert M. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg. 1968;28(1):14–20. https://doi.org/10.3171/jns.1968.28.1.0014.CrossRefPubMed

20.

Claassen J, Bernardini GL, Kreiter K, Bates J, Du YE, Copeland D, Connolly ES, Mayer SA. Effect of cisternal and ventricular blood on risk of delayed cerebral ischemia after subarachnoid hemorrhage: the Fisher scale revisited. Stroke. 2001;32(9):2012–20. https://doi.org/10.1161/hs0901.095677.CrossRefPubMed

21.

Wartenberg KE, Schmidt JM, Temes RE, Frontera JA, Kowalski RG, Ostapkovich N, Sheth SJ, Parra A, Connolly ES, Mayer SA. Medical complications after subarachnoid hemorrhage: frequency and impact on outcome. Stroke. 2005;36(2):521–521.

22.

Ely E, Truman B, Shintani A, et al. Monitoring sedation status over time in icu patients: reliability and validity of the Richmond agitation-sedation scale (rass). JAMA. 2003;289(22):2983–91. https://doi.org/10.1001/jama.289.22.2983.CrossRefPubMed

23.

Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O’Neal PV, Keane KA, Tesoro EP, Elswick RK. The Richmond agitation-sedation scale. Am J Respir Crit Care Med. 2002;166(10):1338–44. https://doi.org/10.1164/rccm.2107138.CrossRefPubMed

24.

de Haan R, Limburg M, Bossuyt P, van der Meulen J, Aaronson N. The clinical meaning of Rankin ‘handicap’ grades after stroke. Stroke. 1995;26(11):2027–30. https://doi.org/10.1161/01.str.26.11.2027.CrossRefPubMed

25.

Azur MJ, Stuart EA, Frangakis C, Leaf PJ. Multiple imputation by chained equations: what is it and how does it work? Int J Methods Psychiatr Res. 2011;20(1):40–9. https://doi.org/10.1002/mpr.329.CrossRefPubMedPubMedCentral

26.

Riker RR, Fugate JE. Clinical monitoring scales in acute brain injury: assessment of coma, pain, agitation, and delirium. Neurocrit Care. 2014;21(2):27–37. https://doi.org/10.1007/s12028-014-0025-5.CrossRef

Title: Duration of Agitation, Fluctuations of Consciousness, and Associations with Outcome in Patients with Subarachnoid Hemorrhage
Authors: Michael E. Reznik
Ali Mahta
J. Michael Schmidt
Hans-Peter Frey
Soojin Park
David J. Roh
Sachin Agarwal
Jan Claassen
Publication date: 01-08-2018
Publisher: Springer US
Published in: Neurocritical Care / Issue 1/2018
Print ISSN: 1541-6933
Electronic ISSN: 1556-0961
DOI: https://doi.org/10.1007/s12028-017-0491-7

2024 ASCO Annual Meeting

Springer Medicine

Duration of Agitation, Fluctuations of Consciousness, and Associations with Outcome in Patients with Subarachnoid Hemorrhage

Abstract

Background

Methods

Results

Conclusion

2024 ASCO Annual Meeting

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

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