Exploring the Significance of Cognitive Motor Dissociation on Patient Outcome in Acute Disorders of Consciousness

Cognitive motor dissociation (CMD) is characterized by a dissociation between volitional brain responses and motor control, detectable only through techniques such as electroencephalography (EEG) and functional magnetic resonance imaging. Hence, it has recently emerged as a major challenge in the assessment of patients with disorders of consciousness. Specifically, this review focuses on the prognostic implications of CMD detection during the acute stage of brain injury. CMD patients were identified in each diagnostic category (coma, unresponsive wakefulness syndrome/vegetative state, minimally conscious state minus) with a relatively similar prevalence of around 20%. Current knowledge tends to indicate that the diagnosis of CMD in the acute phase often predicts a more favorable clinical outcome compared with other unresponsive non-CMD patients. Nevertheless, the review underscores the limited research in this domain, probably at least partially explained by its nascent nature and the lack of uniformity in the nomenclature for CMD-related disorders, hindering the impact of the literature in the field.

Comparison of communication interfaces for mechanically ventilated patients in intensive care

OBJECTIVES

This study aimed to compare the use of a conventional low-tech communication board and a high-tech eye tracking device to improve communication effectiveness of mechanically ventilated patients in intensive care.

DESIGN

A prospective randomized crossover was conducted with a mixed method approach (quantitative primary method and qualitative complementary method) to compare the two technologically opposed communication interfaces.

SETTING

The mechanically ventilated patients were recruited from the general intensive care unit of the Marie Curie Civil Hospital (Charleroi University Hospital, Belgium).

MAIN OUTCOME MEASURES

The communication exchanges were assessed through effectiveness indicators covering the quantity of messages transmitted, success rate, patient satisfaction, communication content and difficulties of use.

RESULTS

The sample consisted of 44 mechanically ventilated patients, covering 88 communication exchanges. The intervention effects on the quantity of messages transmitted (two median messages per exchange for the board versus four median messages per exchange for the eye tracking, p < 0.0001), success rate (80 % for the board versus 100 % for the eye tracking, p < 0.05) and patient satisfaction (66 % "not satisfied", 32 % "satisfied" and 2 % "dissatisfied" for the board versus 52 % "satisfied" and 48 % "very satisfied" for the eye tracking, p < 0.0001) were significant. The communication content covered eight themes for the board compared to nine themes for the eye tracking and the use difficulties included four categories for the board as well as for the eye tracking.

CONCLUSION

The eye tracking device may further improve communication effectiveness of mechanically ventilated patients compared to the conventional communication board, both quantitatively and qualitatively.

IMPLICATIONS FOR CLINICAL PRACTICE

The implementation of high-tech communication devices based on eye tracking in intensive care practice can significantly contribute to patient-centered care by improving communication of mechanically ventilated patients.

Recovery of Acute Leukoencephalopathy Documented by Neuroimaging: A Case Report

Objectives

We describe an atypical delayed neurologic recovery from coma and unresponsive wakefulness syndrome (i.e., persistent vegetative state) in a patient with severe drug-induced toxic leukoencephalopathy (presumably due to synthetic cannabinoid intake).

Methods

The patient underwent standardized behavioral and multimodal neuroimaging assessments to monitor clinical evolution and brain function over a 5-month period after presumed intoxication.

Results

A progressive clinical recovery was observed, from an initial state of coma to emergence from a minimally conscious state after 2 months. Despite the stability of extensive white matter lesions documented by CT and structural MRI, fluorodeoxyglucose PET showed partial recovery of cortical metabolism after 5 months.

Discussion

This case report illustrates that the temporal dynamics of recovery from toxic acute leukoencephalopathy may be atypical and delayed. Multimodal monitoring with repeated behavioral and functional neuroimaging assessments tends to improve the prognosis reliability, while early prognosis based on structural damage may result in misleading statements.

Assessment and management of pain/nociception in patients with disorders of consciousness or locked-in syndrome: A narrative review

The assessment and management of pain and nociception is very challenging in patients unable to communicate functionally such as patients with disorders of consciousness (DoC) or in locked-in syndrome (LIS). In a clinical setting, the detection of signs of pain and nociception by the medical staff is therefore essential for the wellbeing and management of these patients. However, there is still a lot unknown and a lack of clear guidelines regarding the assessment, management and treatment of pain and nociception in these populations. The purpose of this narrative review is to examine the current knowledge regarding this issue by covering different topics such as: the neurophysiology of pain and nociception (in healthy subjects and patients), the source and impact of nociception and pain in DoC and LIS and, finally, the assessment and treatment of pain and nociception in these populations. In this review we will also give possible research directions that could help to improve the management of this specific population of severely brain damaged patients.

Neuroimaging and neurophysiological diagnosis and prognosis in paediatric disorders of consciousness

The diagnosis and prognosis of disorders of consciousness (DOC) such as coma, unresponsive wakefulness syndrome, or minimally conscious state are especially challenging in children. In some paediatric patients with severe acquired brain injury, medical comorbidities or developmental factors may obscure the detection of signs of consciousness via clinical assessments, thus leading to misdiagnosis. To circumvent these biases, patients benefit from multimodal assessments that combine behavioural, neuroimaging, and neurophysiological measures. In this review, we provide original data for such diagnostic procedures in children. Neuroimaging is largely underdocumented in children and most neurophysiological research consists of a cohort study design aimed at providing prognostic markers for clinical outcomes. The scarcity of available data on complementary diagnostic approaches in children makes it difficult to establish clear paediatric guidelines. Although there is preliminary evidence for the applicability of paradigms involving event-related potentials as support for diagnosis in children, more well-designed studies need to be conducted to promote evidence-based practices in paediatric DOC.

Eye Tracking communication with intubated critically ill patients: a proof-of-concept multicenter pilot study

BACKGROUND

Communication is essential to establish patient-caregivers relationship in the intensive care unit. Intubated patients are not able to speak because the tracheal tube prevents vocalization. Use of communication tools such as eye tracking device could improve communication with intubated patients. The objective of this feasibility pilot study was to demonstrate that an eye tracking device specifically developed for the intensive care could be used easily by awake intubated patient with a very short training time.

METHODS

This prospective multicenter study was conducted in four intensive care units. We included awake adult intubated patients. The device used included an eye-tracking infrared detection and a communication interface specifically developed.

RESULTS

A total of 151 patients were included: the median age of patients was 66 years (56-72) and 97 (64%) were male, 97 patients (64%) succeed totally (installation; calibration, succeed to select all three icons), 124 (82%) succeed to select at least one icon, and 111 (74%) succeed to point to at least two icons. The main reasons for failure to use the device were: difficulties to open or to keep the eyes open, difficulties to installing the device occurred, and patient fatigue.

CONCLUSIONS

This study shows that the use of an eye tracking technology device specifically designed for the intensive care setting, with a short training is easy to use for intubated patient. Patients, relatives and caregivers showed high satisfaction.