Abstract
IntroductionSepsis-associated delirium (SAD) increases morbidity in septic patients and, therefore, factors contributing to SAD should be further characterized. One possible mechanism might be the impairment of cerebrovascular autoregulation (AR) by sepsis, leading to cerebral hypo- or hyperperfusion in these haemodynamically unstable patients. Therefore, the present study investigates the relationship between the incidence of SAD and the status of AR during sepsis.MethodsCerebral blood flow velocity was measured using transcranial Doppler sonography and was correlated with the invasive arterial blood pressure curve to calculate the index of AR Mx (Mx>0.3 indicates impaired AR). Mx was measured daily during the first 4 days of sepsis. Diagnosis of a SAD was performed using the confusion assessment method for ICU (CAM-ICU) and, furthermore the predominant brain electrical activity in electroencephalogram (EEG) both at day 4 after reduction of sedation to RASS >-2.Results30 critically ill adult patients with severe sepsis or septic shock (APACHE II 32 ± 6) were included. AR was impaired at day 1 in 60%, day 2 in 59%, day 3 in 41% and day 4 in 46% of patients; SAD detected by CAM-ICU was present in 76 % of patients. Impaired AR at day 1 was associated with the incidence of SAD at day 4 (p = 0.035).ConclusionsAR is impaired in the great majority of patients with severe sepsis during the first two days. Impaired AR is associated with SAD, suggesting that dysfunction of AR is one of the trigger mechanisms contributing to the development of SAD.Trial registrationclinicalTrials.gov ID NCT01029080
Highlights
Sepsis-associated delirium (SAD) increases morbidity in septic patients and, factors contributing to sepsis-associated delirium (SAD) should be further characterized
Thirty patients, five with severe sepsis and twenty-five with septic shock, Acute Physiology and Chronic Health Evaluation (APACHE) II score of 32 ± 6, with a mean age of 64 ± 17 years were included in the study (Table 1)
Impaired AR might be an influencing factor for the development of SAD in these patients. These results suggest that fluctuations in blood pressure, which regularly occur during the first days of sepsis, in combination with the impaired AR might result in Limitations of the study The sedation management with propofol in combination with sufentanil did not influence AR in patients under general anaesthesia and after head injury [24,25,26]
Summary
Sepsis-associated delirium (SAD) increases morbidity in septic patients and, factors contributing to SAD should be further characterized. One possible mechanism might be the impairment of cerebrovascular autoregulation (AR) by sepsis, leading to cerebral hypo- or hyperperfusion in these haemodynamically unstable patients. The present study investigates the relationship between the incidence of SAD and the status of AR during sepsis. A frequent form of central nervous system dysfunction is sepsis-associated delirium (SAD) that can be observed in septic patients [1]. Laboratory and clinical investigations have revealed that cerebral perfusion is reduced during sepsis and cerebrovascular autoregulation (AR) may be impaired [7,8]. All ICU patients who die from septic shock have been shown to have ischemic brain lesions and cerebral haemorrhage has been found in 26% of patients on neuropathologic examination after the patients died [9]. To maintain adequate brain function and neuronal integrity, cerebral blood flow (CBF) under physiologic circumstances is autoregulated within a wide range of cerebral perfusion pressure
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