Identification of risk factors causing sepsis-associated acute brain dysfunction

Objectives: Sepsis is often complicated by signs of acute brain dysfunction ranging from delirium to coma. Neurological findings that occur during the course of sepsis are also called "sepsis-associated encephalopathy (SAE)". In addition to the development of brain damage, SAE causes long-term cognitive impairment, decreased quality of life and increased mortality (1-4). Many mechanisms are implicated in the development of SAE, including neuroinflammation, increased permeability of the blood-brain barrier secondary to cerebral endothelial damage, and activation of microglia in the brain parenchyma (5). Findings such as cerebral ischemic changes, white matter lesions, posterior reversible encephalopathy, atrophy in the frontal cortex and limbic structures detected in neuroimaging studies suggest the presence of acquired brain damage in sepsis (6-8). There are a limited number of studies in the literature regarding the modifiable factors that cause the development of SAE. Many agents such as sedative agents, antibiotics, steroids applied during the intensive care unit cause neurotoxicity. In addition, factors such as metabolic problems, hemodynamic changes and hypoxia due to varying degrees of organ dysfunctions exacerbate encephalopathy findings. Previous studies have shown that SAE has a significant impact on the clinical outcome of the patient. It has been shown that mortality in patients with GCS <8 at the time of admission to the intensive care unit is over 60% (2). It was found that the 28-day mortality rate was higher in patients with SAE when compared with other sepsis patients (9). Two recently published multicenter studies have shown that even mild changes in mental status (for example, GCS 13-14) during admission to ICU increase ICU mortality (10, 11). Our aim in this retrospective study is to determine the potentially modifiable risk factors that cause the development of acute brain dysfunction in patients with sepsis and to determine the prognostic value of these factors. Materials and methods: Various exclusion criteria were determined for the study and 136 patients who were treated with the diagnosis of sepsis in the Reanimation Unit of Istanbul Medical Faculty between January 2015 and December 2019 and who met the study criteria were included. For the study, Approval was obtained from the İ.Ü. Istanbul Medical Faculty Clinical Research Ethics Committee. Data were collected retrospectively from electronic and medical records of sepsis patients treated between 2015-2019. Results: ICU length of stay (P= 0.000), hospitalization time (P=0.036) and ventilation time (P=0.000) were found to be significantly longer in the group with SAE compared to the group without SAE. The entry GCS of the group with SSI was found to be significantly lower than the group without SSI (P=0.017). Patients with Diabetes Mellitus and hematological disease were found to be significantly more common in the group that developed SAE compared to the group that did not develop SAE (P=0.04 and P=0.03, respectively). Hypernatremia (P=0.03) and hyperglycemia development (P=0.002) were found to be significantly more common in the group that developed SAE compared to the group that did not develop SAE. Patients using corticosteroids (64 patients) in the group that developed SAE were found to be significantly more common than the group that did not develop SAE (12 patients) (P=0.047). Gender of the patient (P=0.68), type of admission to the ICU (P=0.073), type of exiting the ICU (P=0.21), type of discharge from hospital (P=0.21), hypertension (P=0.81) , cardiac pathology (P=0.5), pulmonary pathology (P=1), cancer (P=0.09), chronic kidney disease (P=0.191) and other diseases (P=0.26) in terms of the development of SAE no significant difference was found between the two groups. Conclusions: When the groups of patients who developed Acute Brain Dysfunction (106 patients) and did not develop (30 patients) due to sepsis were compared, a significant difference was found in terms of ICU length of stay, hospitalization times, entry GCS values, sedation times, coma times and Mechanical ventilation times. In addition, in patients; Presence of Diabetes Mellitus (DM), hematological disease, infectious agent (especially gram-negative agents), presence of hypernatremia, hyperglycemia, corticosteroid use were determined as risk factors for the development of SAE. Key words: Sepsis-associated encephalopathy, Acute brain dysfunction, delirium, coma.