Behavioral Assessment With the Coma Recovery Scale—Revised Is Safe and Feasible in Critically Ill Patients With Disorders of Consciousness

Matthew R. Woodward, DO; Chris L. Wells, PhD; Shannon Arnold, BA; Farra Dorman, PT; Zaka Ahmed, MBBS; Nicholas A. Morris, MD; Prajwal Ciryam, MD, PhD; Jamie E. Podell, MD; Wan-Tsu W. Chang, MD; W. Denney Zimmerman, DO; Melissa Motta, MD; Bilal Butt, MD; Melissa B. Pergakis, MD; Mohamed Labib, MD; Ting I. Wang, MA; Brian L. Edlow, MD; Neeraj Badjatia, MD; Robynne Braun, MD, PhD; Gunjan Y. Parikh, MD

doi:10.1097/CCE.0000000000001101

Critical Care Explorations (Jul 2024)

Behavioral Assessment With the Coma Recovery Scale—Revised Is Safe and Feasible in Critically Ill Patients With Disorders of Consciousness

Matthew R. Woodward, DO,
Chris L. Wells, PhD,
Shannon Arnold, BA,
Farra Dorman, PT,
Zaka Ahmed, MBBS,
Nicholas A. Morris, MD,
Prajwal Ciryam, MD, PhD,
Jamie E. Podell, MD,
Wan-Tsu W. Chang, MD,
W. Denney Zimmerman, DO,
Melissa Motta, MD,
Bilal Butt, MD,
Melissa B. Pergakis, MD,
Mohamed Labib, MD,
Ting I. Wang, MA,
Brian L. Edlow, MD,
Neeraj Badjatia, MD,
Robynne Braun, MD, PhD,
Gunjan Y. Parikh, MD

Affiliations

Matthew R. Woodward, DO: 1 Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD.
Chris L. Wells, PhD: 2 Department of Rehabilitation Medicine, University of Maryland School of Medicine, Baltimore, MD.
Shannon Arnold, BA: 3 Department of Neurology, University of Maryland School of Medicine, Baltimore, MD.
Farra Dorman, PT: 2 Department of Rehabilitation Medicine, University of Maryland School of Medicine, Baltimore, MD.
Zaka Ahmed, MBBS: 3 Department of Neurology, University of Maryland School of Medicine, Baltimore, MD.
Nicholas A. Morris, MD: 1 Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD.
Prajwal Ciryam, MD, PhD: 1 Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD.
Jamie E. Podell, MD: 1 Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD.
Wan-Tsu W. Chang, MD: 1 Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD.
W. Denney Zimmerman, DO: 1 Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD.
Melissa Motta, MD: 1 Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD.
Bilal Butt, MD: 1 Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD.
Melissa B. Pergakis, MD: 1 Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD.
Mohamed Labib, MD: 5 Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD.
Ting I. Wang, MA: 5 Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD.
Brian L. Edlow, MD: 6 Department of Neurology, Massachusetts General Hospital, Boston, MA.
Neeraj Badjatia, MD: 1 Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD.
Robynne Braun, MD, PhD: 2 Department of Rehabilitation Medicine, University of Maryland School of Medicine, Baltimore, MD.
Gunjan Y. Parikh, MD: 1 Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD.

DOI: https://doi.org/10.1097/CCE.0000000000001101
Journal volume & issue: Vol. 6, no. 7
p. e1101

Abstract

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OBJECTIVES:. Accurate classification of disorders of consciousness (DoC) is key in developing rehabilitation plans after brain injury. The Coma Recovery Scale—Revised (CRS-R) is a sensitive measure of consciousness validated in the rehabilitation phase of care. We tested the feasibility, safety, and impact of CRS-R-guided rehabilitation in the ICU for patients with DoC after acute hemorrhagic stroke. DESIGN:. Retrospective cohort study. SETTING:. This single-center study was conducted in the neurocritical care unit at the University of Maryland Medical Center. PATIENTS:. We analyzed records from consecutive patients with subarachnoid hemorrhage (SAH) or intracerebral hemorrhage (ICH), who underwent serial CRS-R assessments during ICU admission from April 1, 2018, to December 31, 2021, where CRS-R less than 8 is vegetative state/unresponsive wakefulness syndrome (VS/UWS); CRS-R greater than or equal to 8 is a minimally conscious state (MCS). INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. Outcomes included adverse events during CRS-R evaluations and associations between CRS-R and discharge disposition, therapy-based function, and mobility. We examined the utility of CRS-R compared with other therapist clinical assessment tools in predicting discharge disposition. Seventy-six patients (22 SAH, 54 ICH, median age = 59, 50% female) underwent 276 CRS-R sessions without adverse events. Discharge to acute rehabilitation occurred in 4.4% versus 41.9% of patients with a final CRS-R less than 8 and CRS-R greater than or equal to 8, respectively (odds ratio [OR] 13.4; 95% CI, 2.7–66.1; p < 0.001). Patients with MCS on final CRS-R completed more therapy sessions during hospitalization and had improved mobility and functional performance. Compared with other therapy assessment tools, the CRS-R had the best performance in predicting discharge disposition (area under the curve: 0.83; 95% CI, 0.72–0.94; p < 0.0001). CONCLUSIONS:. Early neurorehabilitation guided by CRS-R appears to be feasible and safe in the ICU following hemorrhagic stroke complicated by DoC and may enhance access to inpatient rehabilitation, with the potential for lasting benefit on recovery. Further research is needed to assess generalizability and understand the impact on long-term outcomes.

Published in Critical Care Explorations

ISSN: 2639-8028 (Online)
Publisher: Wolters Kluwer
Country of publisher: United States
LCC subjects: Medicine: Internal medicine: Medical emergencies. Critical care. Intensive care. First aid
Website: https://journals.lww.com/ccejournal/pages/default.aspx

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