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Sepsis-associated Encephalopathy

Septic Encephalopathy


Presentation

  • Twenty-one patients (55%) were found to present confusion. The majority of the patients presented a PI   1.1 (76%).[ncbi.nlm.nih.gov]
  • S100B-positivity is present in more than half of the patients with septic shock.[ncbi.nlm.nih.gov]
  • This Review discusses the epidemiology and clinical presentation of SAE. Recent evidence for SAE pathophysiology is outlined and a diagnostic approach to patients with this syndrome is presented. Lastly, prognosis and management of SAE is discussed.[ncbi.nlm.nih.gov]
  • However, at present, the cellular and molecular mechanisms of SAE have remained elusive. The pathogenesis of SAE is complex and multifactorial, in which activated inflammation is recognized as a major factor.[ncbi.nlm.nih.gov]
  • This review describes the most recent findings in the pathophysiology, diagnosis, and management of sepsis-associated encephalopathy and focuses on its many presentations.[ncbi.nlm.nih.gov]
Confusion
  • Patients underwent a daily cognitive assessment with the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) test. Twenty-one patients (55%) were found to present confusion. The majority of the patients presented a PI   1.1 (76%).[ncbi.nlm.nih.gov]
  • .  Defined as brain dysfunction due to sepsis and SIRS  Also called sepsis-associated delirium  Clinically, acute impairment in the level of consciousness and confusion (manifested by alteration in attention, disorientation and concentration up to[slideshare.net]
  • It can range from slight confusion to coma and can be, although rarely, accompanied by focal neurological signs.[scitechnol.com]
  • This condition can cause mild confusion to deep coma . Wernicke encephalopathy Also known as Wernicke’s disease, this condition is a result of vitamin B-1 deficiency.[healthline.com]
  • […] acute hepatic failure Type B: HE associated with portal-systemic bypass without intrinsic hepatocellular damage Type C: HE associated with end-stage liver disease (ESLD) or cirrhosis with portal-systemic shunt Clinical features HE can range from minimal confusion[clinicaladvisor.com]
Stupor
  • "The first manifestation of SAE is an acute change in mental status, ranging from inattention, disorientation, agitation, somnolence, stupor and coma," the authors write. There is no specific treatment for SAE.[news-medical.net]
  • Arousable by loud voice commands, but immediately lapses into stupor without further response. MAP failed to improve with further increase in norepinephrine. CPP 50 despite increase of ventilatory rate in an effort to decrease ICP.[rense.com]
  • SAE can also lead to stupor and coma. This is the most common encephalopathy in the ICU.[alvinandassociateslnc.com]
  • The overall incidence rate ratio (IRR) for seizures among sepsis survivors was about 5, but was higher for those who also had neurologic dysfunction (such as encephalopathy, delirium, coma, or stupor) during their index hospitalization than in those without[mdedge.com]
Altered Mental Status
  • The main sign of SAE is an altered mental status. Electroencephalography is the more sensitive diagnostic test, and allows the grading of the severity of cerebral dysfunction that is related to outcome.[ncbi.nlm.nih.gov]
  • SAE is characterized by an altered mental status (AMS) that ranges from delirium to coma, and can lead to long-term cognitive impairment.[clinicaltrials.gov]
  • Like altered mental status, and unlike lactate, tachypnea does not require a blood test.[emdocs.net]
  • Neurotoxicity developed 6 days after positive cultures with altered mental status and blood pressure 128/80 mm Hg.[ajnr.org]
  • Back to Top Differential Diagnosis for Hepatic Encephalopathy Distinguishing HE from other acute and chronic causes of altered mental status may be difficult in patients with cirrhosis.[clevelandclinicmeded.com]
Somnolence
  • "The first manifestation of SAE is an acute change in mental status, ranging from inattention, disorientation, agitation, somnolence, stupor and coma," the authors write. There is no specific treatment for SAE.[news-medical.net]
  • […] euphoria or anxiety, shortened attention span, impaired performance of addition or subtraction Grade II Lethargy or apathy, minimal disorientation for time or place, subtle personality change, inappropriate behavior, asterixis usually present Grade III Somnolence[clinicaladvisor.com]
  • Somnolent but can be aroused, unable to perform mental tasks, gross disorientation about time and place, marked confusion, amnesia, occasional fits of rage, present but incomprehensible speech. Stage 4 .[clevelandclinicmeded.com]
Cognitive Defect
  • It has been recently reported that even a single episode of HE is associated with a persistent cognitive defect, suggesting that HE is not a truly reversible condition.[clevelandclinicmeded.com]

Workup

  • When seizure activity must be ruled out, an EEG may be helpful in the initial workup of a patient with cirrhosis and altered mental status. EEG studies are not required to make a confident diagnosis of HE.[clevelandclinicmeded.com]
Brain Edema
  • Both patients showed diffuse brain edema on CT and severe brain dysfunction on electroencephalography within a day of onset.[ncbi.nlm.nih.gov]
  • Brain edema that is clinically significant usually represents a combination of vasogenic and cellular components. Edema can lead to increased ICP as well as tissue shifts and brain displacement from focal processes ( Chap. 274 ).[accessmedicine.mhmedical.com]
  • These therapies include mild hyperventilation which curtails intracerebral blood volume, ventricular drainage of CSF and osmotherapy to reduce brain edema/parenchymal volume.[pulmccm.org]
  • Vasogenic Edema Extent of brain edema was compared between patients from groups 1 and 2, and the results are summarized in Table 4 .[ajnr.org]
  • Ammonia is thought to result in both cytotoxic and vasogenic brain edema due to the cerebral energy failure, excessive intracellular accumilation of glutamine and alteration in aquaporin-4 integral membrane proteins.[clinicaladvisor.com]
White Matter Lesions
  • MRI revealed unilateral subcortical white matter lesions in the right hemisphere. She was diagnosed as having sepsis-associated encephalopathy and was treated with dexamethasone and midazolam.[ncbi.nlm.nih.gov]
  • Nonspecific white matter lesions are also described in other studies. [6] , [7] Finelli and Uphoff reported cases with bilateral basal ganglia, thalamic, cerebellar, brainstem, and cerebral MR abnormalities in sepsis. [8] Furthermore, MR abnormalities[jdrntruhs.org]
  • Etiology of cortical and white matter lesions in cyclosporin-A and FK-506 neurotoxicity . AJNR Am J Neuroradiol 2001 ; 22 : 1901 –14 Schwartz RB, Bravo SM, Klufas RA, et al.[ajnr.org]

Treatment

  • In the patients with a GCS or 13, S100B levels were not influenced by DrotAA treatment. S100B-positivity is present in more than half of the patients with septic shock.[ncbi.nlm.nih.gov]
  • At this moment a specific treatment for SAE does not exist and outcome relies upon prompt and appropriate treatment of sepsis as a whole.[ncbi.nlm.nih.gov]
  • Most therapeutic options center around aggressive treatment of the underlying infection.[ncbi.nlm.nih.gov]
  • Brain edema aggravated and lasted for a few months despite a variety of treatments. MR imaging in the chronic phase revealed cracking lesions extending to the cerebral white matter, the cerebellum, and the brainstem.[ncbi.nlm.nih.gov]
  • At 24 h post-treatment, expression of 117 lncRNAs and 57 mRNAs was consistently elevated, while expression of 79 lncRNAs and 21 mRNAs was decreased (change 1.5-fold; p 0.05).[biorxiv.org]

Prognosis

  • S100A8 might be a better biomarker for diagnosis of SAE and predicting prognosis.[ncbi.nlm.nih.gov]
  • SAE is potentially reversible, but it always worsens the prognosis. Pathophysiology of SAE is not still completely understood, and it is probably multifactorial.[ncbi.nlm.nih.gov]
  • Lastly, prognosis and management of SAE is discussed.[ncbi.nlm.nih.gov]
  • Encephalopathy is a common complication of sepsis, and its onset can occur at any stage of sepsis and implies worse prognosis. However, the incidence, epidemiology, and pathogenesis of sepsis-associated encephalopathy remain controversial.[ncbi.nlm.nih.gov]
  • The aim of this study was to study the clinical significance of serum S100β and NSE in diagnosing sepsis-associated encephalopathy (SAE) and predicting its prognosis. This was a prospective and observational study.[ncbi.nlm.nih.gov]

Etiology

  • "The spectrum of septic encephalopathy: definitions, etiologies, and mortalities." Jama 275.6 (1996): 470-473. Flierl, Michael A., et al. "Pathophysiology of septic encephalopathy—an unsolved puzzle."[derangedphysiology.com]
  • The loss of metabolic regulation of the brain perfusion and local cerebral ischemia additionally contribute to the etiology of septic encephalopathy. A specific therapy is not yet known.[thieme-connect.com]
  • Interestingly - in patients - elevated procalcitonin was associated with delirum in both infectious and non-infectious etiologies.[pulmccm.org]
  • Definitions, etiologies, and mortalities. JAMA. 1996;275(6):470–3 CrossRef PubMed Google Scholar 7. Sonneville R, Verdonk F, Rauturier C et al. Understanding brain dysfunction in sepsis.[link.springer.com]
  • Definitions, etiologies, and mortalities.[springermedizin.de]

Epidemiology

  • However, the incidence, epidemiology, and pathogenesis of sepsis-associated encephalopathy remain controversial. The purpose of this study was to investigate the epidemiological features and risk factors for sepsis-associated encephalopathy.[ncbi.nlm.nih.gov]
  • This Review discusses the epidemiology and clinical presentation of SAE. Recent evidence for SAE pathophysiology is outlined and a diagnostic approach to patients with this syndrome is presented. Lastly, prognosis and management of SAE is discussed.[ncbi.nlm.nih.gov]
  • Leng, Iris (committee member) Santos, Cesar (committee member) date 2009-08-07T14:13:06Z (accessioned) 2010-06-18T19:00:03Z (accessioned) 2009-08-07T14:13:06Z (available) 2010-06-18T19:00:03Z (available) 2009-08-07T14:13:06Z (issued) degree Clinical Epidemiology[wakespace.lib.wfu.edu]
  • He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education.[lifeinthefastlane.com]
  • Página 93 - Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. ‎[books.google.es]
Sex distribution
Age distribution

Pathophysiology

  • Although the pathophysiology of SAE is incompletely understood, it is thought to involve endothelial activation, blood-brain barrier leakage, inflammatory cell migration, and neuronal loss with neurotransmitter imbalance.[ncbi.nlm.nih.gov]
  • This review describes the most recent findings in the pathophysiology, diagnosis, and management of sepsis-associated encephalopathy and focuses on its many presentations.[ncbi.nlm.nih.gov]
  • Further research into the pathophysiology, management and prevention of SAE is needed. This Review discusses the epidemiology and clinical presentation of SAE.[ncbi.nlm.nih.gov]
  • The clinical significance of this pathophysiological finding has to be assessed in further studies.[ncbi.nlm.nih.gov]
  • Pathophysiology of SAE is not still completely understood, and it is probably multifactorial.[ncbi.nlm.nih.gov]

Prevention

  • Further research into the pathophysiology, management and prevention of SAE is needed. This Review discusses the epidemiology and clinical presentation of SAE.[ncbi.nlm.nih.gov]
  • In summary, we found that heat shock could attenuate the electro-cortical dysfunction in rats with LPS-induced septic response, suggesting that heat shock response might potentially be used to prevent SAE in sepsis.[ncbi.nlm.nih.gov]
  • Current philosophy in sepsis management is drifting towards reactivating surviving “dysfunctional/hibernating” cells, including immune system’s own, rather than preventing the non-reachable acute destructive wave of immune activation.[research.pasteur.fr]
  • Is chronic lung disease in low birth weight infants preventable? A survey of eight centers. ‎ Página 84 - Tanner JM, Whitehouse RH, Marubini E, Resele LF. The adolescent growth spurt of boys and girls of the Harpenden growth study. ‎[books.google.es]
  • Página 220 - American Thoracic Society: Hospital-acquired pneumonia in adults: Diagnosis, assessment of severity, initial antimicrobial therapy, and preventive strategies. Am J Respir Crit Care Med 1995;153:1711. ‎[books.google.es]

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