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Published on: March 26, 2019
Impact of a Specialized Care Pathway for ICU Patients With Disorders of Consciousness: Observational Insights From an
Clément Caiazzo1, Estelle Pruvost-Robieux2,3, Ghazi Hmeydia4
1Neurointensive Care Department, GHU-Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Paris, France.
Background:
Management of lasting disorders of consciousness (DoC) is complex and sometimes requires referral of patients to an expert team. We aimed to evaluate the impact of such specialized expert assessment through the description of a single-center experience.
Method:
Monocentric study including all patients with DoC referred to a tertiary neuroICU for multimodal clinical, electrophysiological, and MRI assessment allowing diagnostic and therapeutic proposals and multidisciplinary prognostic prediction. The primary endpoint was the patients' actual outcome, assessed by 3-month functional disability and 1-year mortality, according to the predicted prognosis.
Results:
Between July 2017 to June 2024, 124 patients (median age 61 [49-70] years, 67% of men) were referred from 43 departments of 37 primary hospitals. Most frequent etiologies were post-anoxic encephalopathy (62%) and secondary systemic brain injuries (15%). At a median of 23 [15-33] days after DoC onset, predicted prognosis was good in 20 (16%) patients, intermediate in 41 (33%), and poor in 63 (51%). Three-month GOS-E was 3 [1-3], 2 [1-3], and 1 [1] (p < 0.001) and 1-year mortality was 30%, 41%, and 82% (p < 0.001), respectively. Withdrawal of life-sustaining therapies increased with worsening predicted prognosis (38%, 41%, and 65%, respectively, p < 0.001), but functional disability and mortality remained higher in the poor prognosis group (p < 0.003 and p < 0.039, respectively) even after excluding patients with those decisions.
Conclusion:
Specialized consciousness assessment impacts the ethical decisions made by primary centers and helps refine the prediction of recovery but fails to achieve highly accurate individual prediction in a population with overall poor survival and functional prognosis.
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