States of severely altered consciousness: clinical characteristics, medical complications and functional outcome after rehabilitation.

OBJECTIVE

To identify and characterize demographics, injury variables, complications, and functional outcomes in Asian patients presenting in States of Severely Altered Consciousness (SSAC).

DESIGN

Descriptive case series review.

SETTING/SUBJECTS: Acute rehabilitation unit with intensive, comprehensive neurological rehabilitation program. Thirty consecutive patients diagnosed to be in persistent vegetative state (PVS) or minimally conscious (MCS) state over a 4-year period were included.

MAIN OUTCOME MEASURES

Disability Rating Scale (DRS), Ranchos Los Amigos Scale (RLAS), Modified Barthel Index (MBI).

RESULTS

Seventeen (57%) were male, with a mean age of 31.8 years (median 25y, range 15-74, SD 16.3y). Twenty-one (70%) had traumatic brain injury, and median GCS on acute admission was 5. The mean length of stays (LOS) in acute and rehabilitation facilities was 90.1 days and 106.3 days respectively. Tracheostomized patients had longer acute LOS. (p = 0.03). All patients had improvement in their DRS scores upon rehabilitation discharge. The MBI was insensitive in identifying low-level changes; though paired analyses were significant for improvement. Seventeen (57%) patients were in PVS and the rest in MCS on admission to rehabilitation. Twelve patients progressed to a state of awareness, with eye responses as the most frequent first sign. There was a greater spread of higher RLAS categories on rehabilitation discharge. Urinary tract infection (16 patients, 53%) was the most common medical complication. Nineteen (63%) had central fever and this group was more functionally disabled (p = 0.045). The mean number of medications on discharge was 6. The majority of patients (22 patients, 73%) were discharged home, and patients continued to make functional progress post-discharge.

CONCLUSIONS

Despite SSAC states, the majority improve, however profound disability persists. Possible predictors of a worse outcome include tracheostomy, severity of initial disability, initial RLAS II level and presence of central fever.