Park Kangyun, Froese Logan, Bergmann Tobias, Gomez Alwyn, Sainbhi Amanjyot Singh, Vakitbilir Nuray, Islam Abrar, Stein Kevin Y, Marquez Izzy, Amenta Fiorella, Ibrahim Younis, Zeiler Frederick A
Undergraduate Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada.
Neurotrauma Rep. 2024 Oct 2;5(1):916-956. doi: 10.1089/neur.2024.0090. eCollection 2024.
Neurointensive care primarily focuses on secondary injury reduction, utilizing a variety of guideline-based approaches (including administration of high-dose sedation) to reduce the injured state. However, titration of sedation is currently based on the Richmond Agitation Sedation Scale (RASS), a subjective clinical grading score of a patient's response to external physical stimuli, and not an objective measure. Therefore, it is likely that there exists substantial variation in objective sedation depth for a given clinical grade in these patients, leading to undesired sedation depths and cerebral physiological consequences. Improper sedation can impede cerebral autoregulation, emphasizing the critical need for optimal sedation in traumatic brain injury (TBI) patients. This study evaluates the relationship between RASS to an objective measure of depth of sedation (bispectral index, BIS) and cerebral physiological measures. Fifty-nine patients were assessed using Jonckheere-Terpstra testing to compare various key physiologies with RASS. RASS (-5 through 0 categories) showed no statistically significant relationship between BIS and cerebral physiological parameters, after adjusting for multiple comparisons. Furthermore, it is crucial to note that within each RASS value, the distribution of the physiological measures all had high variability. As an exemplar, for RASS values of -5 and -4, BIS ranged from near 0 (burst suppression levels) up to over 80 (near awake states). BIS and other cerebral physiologies displayed substantial variation across each RASS category. This suggests that RASS as a means to titrate sedative medication for the goal of neuroprotection is insufficient. More momentary, individualized determination of sedation depth is required for TBI patients.
神经重症监护主要侧重于减少继发性损伤，采用各种基于指南的方法（包括给予大剂量镇静）来减轻损伤状态。然而，目前镇静的滴定是基于里士满躁动镇静量表（RASS），这是一种对患者对外界物理刺激反应的主观临床分级评分，而非客观测量。因此，对于这些患者的给定临床分级，客观镇静深度可能存在很大差异，导致不期望的镇静深度和脑生理后果。不当的镇静会阻碍脑自动调节，凸显了创伤性脑损伤（TBI）患者最佳镇静的迫切需求。本研究评估了RASS与镇静深度的客观测量指标（脑电双频指数，BIS）及脑生理测量指标之间的关系。使用琼克尔-特普斯特拉检验对59例患者进行评估，以比较各种关键生理指标与RASS的关系。在进行多重比较校正后，RASS（-5至0类别）在BIS与脑生理参数之间未显示出统计学上的显著关系。此外，需要注意的是，在每个RASS值范围内生理测量指标的分布都具有很高的变异性。例如，对于RASS值为-5和-4时，BIS范围从接近0（爆发抑制水平）到超过80（接近清醒状态）。BIS和其他脑生理指标在每个RASS类别中都表现出很大差异。这表明RASS作为一种为神经保护目标滴定镇静药物的方法是不够的。TBI患者需要更即时、个性化的镇静深度测定。
