Intensive Care Med (2014) 40:484–495 DOI 10.1007/s00134-014-3214-y CONFERENCE REPORTS AND EXPERT PANEL

Tarek Sharshar of critically ill Giuseppe Citerio Peter J. D. Andrews patients: a pragmatic approach. Report Arturo Chieregato Nicola Latronico of an ESICM expert panel David K. Menon Louis Puybasset Claudio Sandroni Robert D. Stevens

L. Puybasset examination (NE) of the critically ill Received: 5 December 2013 Neuro , Department of Accepted: 8 January 2014 patient. Methods: The group con- Anesthesia and Intensive Care Pitie´- Published online: 13 February 2014 ducted a comprehensive review of Salpeˆtrie`re Hospital, University Pierre et Ó Springer-Verlag Berlin Heidelberg and published studies on the NE of ESICM 2014 Marie Curie, Paris VI, Assistance-Publique Hoˆpitaux de Paris, Paris, France patients with , delirium, seizures This document has been endorsed by the and neuromuscular weakness in crit- European Society of Intensive Care C. Sandroni ically ill patients. Quality of data was . Department of Anaesthesiology and rated as high, moderate, low, or very Intensive Care, Catholic University School low, and final recommendations as of Medicine, Rome, Italy strong, weak, or best practice. Sum- T. Sharshar ()) mary and Conclusions: The group Service de Re´animation Polyvalente made the following recommenda- Raymond Poincare´ Teaching Hospital, tions: (1) NE should be performed in University of Versailles, Assistance- all patients admitted to ICUs; (2) NE Publique Hoˆpitaux de Paris, Garches, should include an assessment of P. J. D. Andrews France and cognition, brain- Centre for Clinical Brain Sciences and NHS e-mail: [email protected] stem function, and motor function; Lothian, Western General Hospital, T. Sharshar (3) sedation should be managed to University of Edinburgh, Edinburgh EH4 maximize the clinical detection of 2XU, UK Laboratoire d’Histopathologie et de Mode`les Animaux Instiut Pasteur, Paris, neurological dysfunction, except in A. Chieregato France patients with reduced intracranial Anaesthesia and , compliance in whom withdrawal of CTO, Azienda Ospedaliera Universitaria R. D. Stevens sedation may be deleterious; (4) the Careggi, Florence, Italy Neurosciences Critical Care Division, Johns need for additional tests, including Hopkins University School of Medicine, Baltimore, MD, USA neurophysiological and neuroradio- G. Citerio logical investigations, should be Neuroanaesthesia and Unit, Anestesia e Rianimazione, San guided by the NE; (5) selected fea- Gerardo Hospital, Monza, Milan, Italy Abstract Objective: Many tures of the NE have prognostic value patients admitted to the intensive care which should be considered in well- N. Latronico unit (ICU) have pre-existing or defined patient populations. University Division of Anesthesia and acquired neurological disorders Intensive Care Medicine, University of which significantly affect their short- Keywords Coma Á Brescia, Brescia, Italy term and long-term outcomes. The Neurological examination Á ESICM NeuroIntensive Care Section D. K. Menon Critical illness Á Sedation Á Delirium Á Department of Anaesthesia, University of convened an expert panel to establish Cambridge, Cambridge, UK a pragmatic approach to neurological 485

Introduction 1. What are the essential components of the clinical neurological assessment in the ICU? Clinical examination is the cornerstone of the assess- 2. Which critically ill patients should be examined ment of patients with primary neurological conditions neurologically? leading to intensive care unit (ICU) admission, and also 3. How should sedation be managed to facilitate neuro- for the detection of neurological disorders complicating logical assessment? critical illness. It is the basis for neuroanatomical 4. How should coma be assessed in critically ill patients? localization of a disease process. It may help to identify 5. How should delirium be assessed in critically ill a previously undiagnosed neurological disease, such as patients? myasthenia gravis in a patient who is failing liberation 6. What are the clinical criteria which should prompt from the ventilator, or pre-existing cognitive decline in a magnetic resonance imaging in patients who are patient who develops delirium. The diagnosis of neuro- admitted without primary neurological diagnosis? logical disorders in the ICU may lead to therapeutic 7. How should patients be evaluated for ICU-acquired interventions, because a specific treatment is needed muscle weakness? (e.g., the institution of anticonvulsant therapy) or contra- 8. What are the clinical criteria which should prompt indicated (e.g., therapeutic anticoagulation in a patient nerve conduction studies and electromyography? with intracerebral hemorrhage), or to determine physi- 9. What is the prognostic value of neurological signs? ological goals (e.g., management of blood pressure in ischemic stroke). The identification of a neurological The place of EEG in the neurological assessment and disorder will also orient prognosis and the need for and of critically ill patients has been extensively type of rehabilitation. Critical care providers need skills addressed in a recent systematic review by Claassen et al. to (1) determine nature and severity of neurological [1]. dysfunction, (2) establish a neurological differential diagnosis, and (3) to determine a plan for further neu- rological testing and treatment. Currently, there are no Search strategy recommendations for NE of critically ill patients. To address this gap, the ESICM NeuroIntensive Care Sec- The PubMed database was searched (from 1996 to Sep- tion (NIC) convened an expert panel of intensivists, tember 2012) for observational studies and clinical trials neuro-intensivists, anesthesiologists, and neurologists to in adults using the following terms: ‘‘coma’’, ‘‘delirium’’, establish a pragmatic framework for the NE of critically ‘‘confusion’’, ‘‘agitation’’, ‘‘consciousness’’; ‘‘psychosis’’, ill adult patients. ‘‘encephalopathy’’, ‘‘brain dysfunction’’, ‘‘seizure’’, ‘‘muscle weakness’’; ‘‘paresis’’, ‘‘critical illness poly- neuropathy’’, ‘‘critical illness myopathy’’, ‘‘critical illness neuromyopathy’’; with one of the following: ‘‘critical Methods illness’’, ‘‘critically ill patients’’, ‘‘intensive care’’, ‘‘sep- sis’’, ‘‘sedation’’, ‘‘’’. Only studies Expert panel containing a description of the NE in critically ill popu- lations were included. Review articles, animal studies, The members of the expert panel were nominated at a and studies conducted in pediatric populations were meeting of the NIC in March 2010. Participants are excluded. senior academic intensivists with training in anesthe- siology, critical care medicine, and . The panel-members were asked to perform an evidence- Rating of evidence and recommendations based review and to write a concise summary with grading of the level of evidence and recommendations. Quality of data and strength of final recommendations These summaries were merged in a single manuscript were rated high, moderate, low, or very low, and rec- which was then reviewed and edited by the entire ommendations were rated as strong or weak. Some panel. recommendations were based not on published evidence but on clinical standard of care acknowledged by all the experts. These were designated as ‘‘best practice recom- Questions addressed by the panel mendation’’. All the recommendations were reviewed and approved by all members of the panel. In cases of dis- The group identified nine key domains relating to the agreement, recommendations were modified, in order to clinical NE of critically ill patient and each panel member be unanimously accepted. Therefore, all the members was tasked with responding in their summaries to one or agreed with the content of the manuscript and the rec- two of the questions: ommendations proposed here. 486

Question 1: what are the essential components 3. Coma, delirium, and motor strength should be evalu- of the clinical neurological assessment in the ICU? ated using validated scales (respectively GCS or FOUR; CAM-ICU or ICDSC; and MRC—moderate Disturbances in neurological function are prevalent in the evidence, strong recommendation. ICU, both as expressions of primary neurological injury and of systemic organ failure. Neurological signs indicate severity of illness and independently predict outcome [2– Question 2: which critically ill patients should be 9]. Altered consciousness, delirium, agitation, anxiety, examined neurologically? pain, sedation, neuromuscular blockade, hypothermia, intubation/mechanical ventilation, and surgical or trau- Neurological dysfunction including altered conscious- matic lesions of the extremities may confound ness, delirium, seizures, and muscle weakness are neurological assessment in the ICU [10]. Notwithstand- exceedingly common in critically ill patients [21]. More ing, NE is feasible in the ICU and has major diagnostic than 80 % of mechanically ventilated patients may and prognostic significance [2, 11, 12]. experience delirium in the ICU [22]. Depressed con- The structure of the NE is determined by the level of sciousness is the major contributor to prolonged consciousness: ventilation in a third of those who need it and a significant factor in an additional 40 % [23, 24]. Neurological (a) In the conscious patient, the clinician assesses cog- complications increase both the length of stay in hospital nition (orientation, language, attention, memory), and the likelihood of death [23]. The mortality rate for cranial nerves, motor and sensory function, reflexes, patients with neurological complications is 55 % com- and coordination. The comprehensiveness and struc- pared to 29 % for those without [25]. Critical illnesses ture of this examination must be adapted to the have been associated with substantial long-term declines underlying neurological process. Serial examinations in neuropsychological function [26, 27, 28]. are necessary to discern trends and evidence of deterioration. Once sedation is interrupted [13], delirium and coma should be scored using validated Recommendations instruments [4, 14, 15], as detailed below. Muscular 1. All critically ill patients should undergo routine NE— strength should be tested using the validated Medical moderate evidence, best practice recommendation. Research Council (MRC) scale [6, 16] (Table 1). (b) In the comatose patient, neurological assessment considers level of arousal, brainstem function, motor Question 3: how should sedation be managed to facilitate responses, and respiratory pattern [15]. Numerical neurological assessment? scales generally used for this purpose are the Glasgow Coma Scale (GCS) [17] or The Full Outline of In the ICU, routine interruption of continuous sedation Unresponsiveness (FOUR) scale, as detailed in (ICS) has been associated with reduced duration of Table 2 and below [18] (see also Figs. 1, 2). In both mechanical ventilation and decreased overall ICU length traumatic and post-anoxic coma, brainstem semiology is critical: absence of pupillary reactivity and abnor- mal motor responses are prognostically significant Table 1 Medical Research Council (MRC) sumscore [11, 19, 20], while loss of the corneal response signals Score for each movement poor outcome in post-anoxic coma [11]. 0 = no visible contraction 1 =