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Summary: The definition of consciousness has been the subject of great interest for many scientists and philosophers. To better understand how evoked potentials may be identified as biomarkers of consciousness and recovery, the different theoretical models sustaining neural correlates of consciousness are reviewed. A multimodal approach can help to better predict clinical outcome in patients presenting with disorders of consciousness. Evoked potentials are inexpensive and easy-to-implement bedside examination techniques. Evoked potentials are an integral part of prognostic evaluation, particularly in cases of cognitive motor dissociation. Prognostic criteria are well established in postanoxic disorders of consciousness, especially postcardiac arrest but are less well determined in other etiologies. In the early examination, bilateral absence of N20 in disorder of consciousness patients is strongly associated with unfavorable outcome (i.e., death or unresponsive wakefulness syndrome) especially in postanoxic etiologies. This predictive value is lower in other etiologies and probably also in children. Both N20 and mismatch negativity are proven outcome predictors for acute coma. Many studies have shown that mismatch negativity and P3a are characterized by a high prognostic value for awakening, but some patients presenting unresponsive wakefulness syndrome also process a P3a. The presence of long-latency event-related potential components in response to stimuli is indicative of a better recovery. All neurophysiological data must be integrated within a multimodal approach combining repeated clinical evaluation, neuroimaging, functional imaging, biology, and neurophysiology combining passive and active paradigms.

Resume Introduction Les etudes medicales ont recemment connu de nombreux changements, notamment la reforme du troisieme cycle, une actualite de burn-out des professionnels et la loi des 48 heures du travail par semaine. Dans ce contexte, les auteurs ont cherche a caracteriser les aspirations professionnelles des nouveaux internes. Methodes La population etait les internes d’anesthesie-reanimation en France de l’annee 2017–2018 avant leur debut d’internat. Un questionnaire leur est parvenu par message via un reseau social en ligne. La population etait interrogee sur l’importance accordee a ces criteres : reconnaissance sociale et professionnelle, avoir des responsabilites, salaire eleve, qualite de vie, ambiance au travail, formation et evolution des competences, geographie du lieu de travail. Une description demographique a ete realisee. Resultats, discussion Quatre cent trois neo-internes d’anesthesie-reanimation ont ete inclus dans l’etude. Trente-huit pour cent etaient des femmes. L’anesthesie-reanimation etait le premier choix pour 93 % des internes. La cardiologie etait l'activite la plus attractive et apparaissait en deuxieme choix. L’activite mixte anesthesique-reanimation etait la plus souhaitee, par 55 % des neo-internes, suivie par l’anesthesie (18 %) et la reanimation medicale (6,5 %). L’activite SMUR exclusive etait souhaitee par 2 etudiants (0,4 %). Les plus importants criteres retenus pour l’exercice professionnel etaient l’ambiance, la qualite de vie et l’evolution des competences. La reconnaissance sociale etait le critere le moins important. Conclusion L’anesthesie-reanimation reste un choix positif pour la quasi-totalite des internes. La qualite de vie et l’ambiance au travail sont desormais des criteres de choix pour les internes. La polyvalence de la formation est recherchee par la majorite des futurs anesthesistes-reanimateurs.

Decisions of withdrawal of life-sustaining therapy for patients with severe brain injury are often based on prognostic evaluations such as analysis of electroencephalography (EEG) reactivity (EEG-R). However, EEG-R usually relies on visual assessment, which requires neurophysiological expertise and is prone to inter-rater variability. We hypothesised that quantitative analysis of EEG-R obtained 3 days after patient admission can identify new markers of subsequent awakening and consciousness recovery.In this prospective observational study of patients with severe brain injury requiring mechanical ventilation, quantitative EEG-R was assessed using standard 11-lead EEG with frequency-based (power spectral density) and functional connectivity-based (phase-lag index) analyses. Associations between awakening in the intensive care unit (ICU) and reactivity to auditory and nociceptive stimulations were assessed with logistic regression. Secondary outcomes included in-ICU mortality and 3-month Coma Recovery Scale-Revised (CRS-R) score.Of 116 patients, 86 (74%) awoke in the ICU. Among quantitative EEG-R markers, variation in phase-lag index connectivity in the delta frequency band after noise stimulation was associated with awakening (adjusted odds ratio=0.89, 95% confidence interval: 0.81-0.97, P=0.02 corrected for multiple tests), independently of age, baseline severity, and sedation. This new marker was independently associated with improved 3-month CRS-R (adjusted β=-0.16, standard error 0.075, P=0.048), but not with mortality (adjusted odds ratio=1.08, 95% CI: 0.99-1.18, P=0.10).An early-stage quantitative EEG-R marker was independently associated with awakening and 3-month level of consciousness in patients with severe brain injury. This promising marker based on functional connectivity will need external validation before potential integration into a multimodal prognostic model.

Resume L’encephalopathie liee au sepsis (EAS) est une complication des infections severes. Son diagnostic repose sur l’examen clinique et est formalise par des check-lists ou des algorithmes. Son incidence est estimee a 20–40 % des patients admis en reanimation pour une infection. Elle se traduit par des anomalies de l’examen clinique, telles que des troubles de la conscience ou de la vigilance, associes a des anomalies electroencephalographiques ou radiologiques. La survenue de crises convulsives generalisees est rare, bien que les anomalies epileptiques soient frequentes a l’EEG. Des signes neurologiques de localisation sont parfois observes, souvent en rapport avec des accidents ischemiques ou hemorragiques intracrâniens. L’EAS est pourvoyeuse de troubles psychologiques (anxiete, depression, suicide) et cognitifs a long terme, alterant la qualite de vie des patients, mais egalement d’une surmortalite probablement en rapport avec la persistance de troubles de la deglutition. Sa physiopathologie implique des processus neuro-inflammatoires ischemiques, associes a des perturbations metaboliques, conduisant a une crise metabolique et a une mort cellulaire. Des perturbations de l’autoregulation cerebrale ont recemment ete mises en evidence. A ce jour, il n’existe pas de strategie pharmacologique ciblant la neuro-inflammation, ni la neuro-transmission (y compris une strategie de sedation) permettant de reduire l’incidence, la duree ou la severite de l’EAS. Les interventions non pharmacologiques proposees pour la prevention ou le traitement du delirium doivent etre appliquees chez les patients septiques, notamment la mobilisation precoce, l’arret de la sedation et la rehydratation, la prise en charge des inconforts physiques et psychologiques et le retrait des medicaments pro-delirants.

Septic-associated encephalopathy (SAE) is a key manifestation of sepsis, ranging from delirium to coma and occurring in up to 70% of patients admitted to the ICU. SAE is associated with higher ICU and hospital mortality, and also with poorer long-term outcomes, including cognitive and functional outcomes. The pathophysiology of SAE is complex, and it may involve neurotransmitter dysfunction, inflammatory and ischemic lesions to the brain, microglial activation, and blood–brain barrier dysfunction. Delirium (which is included in the SAE spectrum) is mostly diagnosed with validated scales in the ICU population. There is no established treatment for SAE; benzodiazepines should generally be avoided in this setting. Nonpharmacological prevention and management is key for treating SAE; it includes avoiding oversedation (mainly with benzodiazepines), early mobilization, and sleep promotion. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s13311-020-00862-1) contains supplementary material, which is available to authorized users.

Objectives Acute respiratory failure is a frequent complication of Guillain-Barre syndrome, associated with high morbidity and mortality. Adjuvant treatments are needed to improve the outcome of Guillain-Barre syndrome. Since dysglycemia is a risk factor for development of axonal polyneuropathy in critically ill patients and since insulin therapy may be neuroprotective, we sought to explore the association between dysglycemia and neurologic status in Guillain-Barre syndrome patients. Design Retrospective study. Setting Single-center study. Interventions All plasma levels of glycemia measured by enzymatic technique as well as capillary glycemia were collected in a cohort of mechanically ventilated Guillain-Barre syndrome patients. Insulin administration and dysglycemia were correlated to neurologic status at discharge defined by disability grade and arm grade. Measurements and main results In a multivariate analysis, disability grade and arm grade at ICU discharge were independently and inversely correlated with mean blood glucose. Disability grade and arm grade did not correlate with any other dysglycemic variables or with insulin administration or length of stay. Conclusions In the present study, we found that neurologic disability at ICU discharge correlated with dysglycemia in mechanically ventilated Guillain-Barre syndrome patients. These finding indicates that dysglycemia may delay motor recovery and impact the functional outcome of Guillain-Barre syndrome. Blood glucose control might be an adjuvant therapy for improving Guillain-Barre syndrome recovery.