Thesis and blogs

RISK FACTORS, CLINICAL SPECTRUM, DIAGNOSTIC AND OUTCOME PREDICTORS OF PATIENTS WITH ENCEPHALOPATHY

DR. HARI PRIYA

POST GRADUATE IN GENERAL MEDICINE DEPARTMENT

KAMINENI INSTITUTE OF MEDICAL SCIENCES

KALOJI NARAYANA RAO UNIVERSITY OF HEALTH SCIENCES

Loading…

INTRODUCTION

•ENCEPHALOPATHY is a broad term for any diffuse disease of the brain that alters brain structure or function. The hall mark of encephalopathy is altered mental status.

•Encephalopathy may be caused by bacteria, virus, or prion, metabolic or mitochondrial dysfunction, ischemic or hypoxic ,brain tumour or increased intracranial pressure, long standing exposure to toxic substances like drugs, radiation, solvents, paints, industrial chemicals, and certain metals, trauma, poor nutrition, or lack of oxygen or blood flow to the brain.

•In febrile illness, multiple pathogenic mechanisms can contribute to the encephalopathy. Pathological process can directly affect the central nervous system or indirectly affecting the central nervous system through systemic complications such as hypovolemia, hypoglycaemia, hypoxia, anaemia, hepatic failure, renal failure and bleeding.

•Clinically it is synonymously used with multiple terminologies including altered sensorium, altered mental status and change in mental status.

•It is important to understand normal mental status to identify patients with altered mental status.

INTRODUCTION

Loading…

•MENTAL STATUS is a combination of patient’s level of consciousness and cognition.

•Normal mental status is when the patient has normal level of consciousness and the content of consciousness is normal. Consciousness is the quality or state of being aware especially of something within oneself.

•The terms used to describe different level of consciousness are

1.NORMAL OR ALERT

2.DROWSY OR LETHARGIC

3.VIGILANT OR HYPERALERT

4.STUPOR

5.COMA

INTRODUCTION

•The Content of consciousness include

1.ORIENTATION

2.ATTENTION

3.EXECUTIVE FUNCTION

4.LANGUAGE

5.MEMORY

6.PERCEPTION

•Normal mental status when impaired is termed altered mental status which can be either an altered level of consciousness ranging from being vigilant or hyper alert to being drowsy, stupor or comatose or an impairment in the content of the consciousness or a combination of both.

INTRODUCTION

•ALTERED MENTAL STATUS (AMS) is used to describe different states of mental functioning that can vary between mild confusion to coma.

•Different synonyms are used in the literature to describe this state such as, not acting right, confusion, altered behaviour, altered sensorium, lethargy, agitation, psychosis, disorientation, inappropriate behaviour, in attention.

•The understanding of these terminologies will help us in identification of the problem early and also to document it accurately so that further worsening or improvement can be assessed.

INTRODUCTION

AIM :

•TO STUDY THE RISK FACTORS , CLINICAL SPECTRUM AND OUTCOMES OF PATIENTS PRESENTING WITH ENCEPHALOPATHY

OBJECTIVES:

•To study the risk factors & etiology of patients presenting with encephalopathy

•To study the clinical and laboratory predictors in the diagnosis of etiology (Infectious and non-infectious) of encephalopathy

•To assess the outcome (Mortality and functional outcome) of patients with encephalopathy .

• To study the predictors of outcome in patients with encephalopathy

MATERIALS & METHODS:

PLACE OF STUDY: GENERAL MEDICINE DEPARTMENT, KAMINENI INSTITUTE OF MEDICAL SCIENCES

STUDY PERIOD: OVER 2 YEARS ( OCT 2022 – AUG 2024)

STUDY DESIGN : PROSPECTIVE OBSERVATIONAL STUDY

SAMPLE SIZE: 50 PATIENTS

SAMPLE POPULATION: PATIENTS OF AGE 18- 65YRS ATTENDING MEDICINE DEPARTMENT IN KAMINENI INSTITUTE OF MEDICAL SCIENCE

Loading…

•The study has been approved by the ethics committee of kamineni institute of medical sciences, narketpally.

•All patient satisfying the inclusion criteria will be enrolled in the study.

•A written informed consent will be taken from the patients prior to the start of the study

INCLUSION CRITERIA:

1. Patients with age from 18years-65years.

2. Written informed consent from each patient or legal guardian prior to enrolment patients age 18-65 years

3. All patients with signs & symptoms suggestive of encephalopathy(defined as any form of altered sensorium/altered level of consciousness)

EXCLUSION CRITERIA:

•1.Patients with Age less than 18 years

•2.Patients who haven’t given Consent

•3. Patients who are not capable of giving consent (mentally ill patients)

•4. Patients in encephalopathy with focal neurological deficit

METHODOLOGY:

•30 random patients (n=30) who were hospitalized for altered sensorium as well as satisfied our inclusion & exclusion criteria were selected for this study.

•All patients underwent full medical and neurologic clinical evaluation and Glasgow Coma Scale grading at the time of admission (time of admission to study was arbitrarily taken as the time of first neurologic assessment).

•Laboratory investigations included complete blood count, renal function test, serum electrolytes,random blood sugars,liver function test, urine routine examination. ECG and X-Ray chest were done for all patients. CSF examination (in suspected cases of meningo encephalitis), CT &MRI brain and other investigations were done as and when required.

METHODOLOGY:

•Patients were neurologically evaluated daily and the progression was monitored with Glasgow Coma Scale scoring.

•All patients were followed till discharge and at one month.

• Outcome was graded and recorded into 2 categories:

•I – Death (Mortality)

•II – Good recovery

•The history, general examination, the neurological profile at the time of admission, important positive investigation findings, the diagnosis and outcome of all cases are presented in tabular form (master chart) and analysed.

PROFORMA:

• Serial No.

• Name:

• Age:

• Occupation:

• Address :

• OP NO./IP NO.

• D.O.A:

• D.O.D

PROFORMA:

ETIOLOGY:

INFECTIOUS

METABOLIC

•HYPERTHERMIA

•HYPONATREMIA

•HYPERGLYCEMIA/HYPOGLYCEMIA

•HYPOXIA , HYPERCAPNIA

•HEPATIC/UREMIC ENCEPHALOPATHY

•TOXINS –ALCOHOL RELATED,DRUGS

PROFORMA:

OUTCOMES:

•MORTALITY

•MORBIDITY AT DISCHARGE AND AT ONE MONTH.

OBSERVATION & RESULTS

•A total of 30 patients with altered sensorium admitted to our hospital kamineni institute of medical sciences were studied over a period of 1 year and the following results were obtained.

TABLE NO 1: AGE WISE DISTRIBUTION (n=30)

AGE

TOTAL

18-20

21-30

31-40

41-50

51-60

61-70

71-80

81-90

CHART NO 1: AGE WISE DISTRIBUTION (n=30)

Age in years

TABLE NO 2: GENDER WISE DISTRIBUTION (n=30)

GENDER

TOTAL

MALE

FEMALE

Loading…

TABLE NO 3: SYMPTOMS WISE PATIENT DISTRIBUTION (n=30)

SYMPTOMS

TOTAL

FEVER

HEADACHE

VOMITING

SEIZURES

NUCHAL RIGIDITY

JAUNDICE

COUGH/DYSPNEA

BURNING MICTURITION/ANURIA

CHART NO 3: SYMPTOMS WISE PATIENT DISTRIBUTION (n=30)

TABLE NO 4: COMORBIDITIES WISE PATIENT DISTRIBUTION (n=30)

COMORBIDITIES

TOTAL

HTN

CKD

CLD

CHART NO 4: COMORBIDITIES WISE PATIENT DISTRIBUTION (n=30)

TABLE NO 5: ETIOLOGY WISE PATIENT DISTRIBUTION (n=30)

ETIOLOGY

TOTAL

INFECTIOUS

BACTERIAL/TB

VIRAL

PARASITE(Malaria)

NON

INFECTIOUS

METABOLIC(HYPONATREMIA,

HYPOGLYCEMIA,HYPERGLYCEMIA,UREMIC,HEPATIC,HYPOXIC ENCEPHALOPATHY)

TOXINS(ALCOHOL,SEPTIC)

CHART NO 5: ETIOLOGY WISE PATIENT DISTRIBUTION (n=30)

TABLE NO 6: AGE AND PATIENT OUTCOME (n=30)

AGE IN

YEARS

PATIENT ALIVE

n(%)

PATIENT DIED

n(%)

TOTAL

n(%)

P value

(95% CI)

18 - 40

5(16.6%)

1(3.3%)

6(29%)

> 40

17(56.6%)

6(20%)

23(76.6%)

TOTAL

n(%)

23(76.6%)

7(23.3%)

TABLE NO 7: GENDER AND PATIENT OUTCOME (n=30)

GENDER

PATIENT ALIVE

n(%)

PATIENT DIED

n(%)

TOTAL

n(%)

Chi-square

ᵪ2

(95% CI)

MALE

16(53.3%)

5(16.6%)

21(70%)

FEMALE

7(23.3%)

2(6.6%)

9(30%)

TOTAL

n(%)

23(76.6%)

7(23.3%)

CHART NO 7: GENDER AND PATIENT OUTCOME (n=30)

TABLE NO 8: SYMPTOMS AND PATIENT OUTCOME (n=30)

SYMPTOMS

PATIENT ALIVE

n(%)

PATIENT DIED

n(%)

TOTAL

n(%)

P value

(95% CI)

FEVER

YES

6(20%)

4(13.3%)

10(33.3%)

17(56.6%)

3(10%)

20(66.6%)

HEADACHE

YES

5(16.6%)

2(6.6%)

7(23.3%)

18(60%)

5(16.6%)

23(76.6%)

VOMITING

YES

10(33.3%)

3(10%)

13(43.3%)

4(13.3%)

17(56.6%)

SEIZURES

YES

1(3.3%)

2(6.6%)

3(10%)

22(73.3%)

5(16.6%)

27(90%)

NUCHAL RIGIDITY

YES

2(6.6%)

23(76.6%)

5(16.6%)

28(93.3%)

TABLE NO 9: SIGNS AND PATIENT OUTCOME (n=30)

SIGNS

PATIENT ALIVE

n(%)

PATIENT DIED

n(%)

TOTAL

n(%)

P value

(95% CI)

GCS

≥ 8

23(76.6%)

5(16.6%)

28(93.3%)

< 8

2(6.6%)

RR (cpm)

> 20

1(3.3%)

2(6.6%)

≤ 20

22(73.3%)

6(20%)

28(93.3%)

PR (bpm)

> 100

5(16.6%)

10(33.3%)

≤ 100

18(60%)

2(6.6%)

20(66.6%)

MAP (mmHG)

≥ 65

20(66.6%)

5(16.6%)

25(83.3%)

< 65

3(10%)

2(2.2%)

5(16.6%)

SPO2 (%)

≥ 92

22(73.3%)

5(16.6%)

27(90%)

< 92

1(3.3%)

2(6.6%)

3(10%)

CHART NO 9: SIGNS AND PATIENT OUTCOME (n=30)

TABLE NO 10: COMORBIDITIES AND PATIENT OUTCOME (n=30)

COMORBIDITIES

PATIENT ALIVE

n(%)

PATIENT DIED

n(%)

TOTAL

n(%)

P value

(95% CI)

YES

9(30%)

4(13.3%)

13(43.3%)

14(46.6%)

3(10%)

17(56.6%)

HTN

YES

5(16.6%)

1(3.3%)

6(20%)

18(60%)

6(20%)

24(80%)

YES

1(3.3%)

2(6.6%)

3(10%)

22(73.3%)

5(16.6%)

27(90%)

CKD

YES

4(13.3%)

1(3.3%)

5(16.6%)

19(63.3%)

6(20%)

25(83.3%)

CLD

YES

3(10%)

6(20%)

20(66.6%)

4(13.3%)

24(80%)

TABLE NO 11: LAB DATA AND PATIENT OUTCOME (n=30)

LAB DATA

PATIENT ALIVE

n(%)

PATIENT DIED

n(%)

TOTAL

n(%)

P value

(95% CI)

WBC

(cells/cumm)

> 10000

19(63.3%)

4(13.3%)

23(76.6%)

4000 - 10000

4(13.3%)

3(10%)

7(23.3%)

RBS

(mg/dl)

≥ 70

20(66.6%)

7(23.3%)

27(90%)

< 70

3(10%)

SERUM UREA

(mg/dl)

> 40

10(33.3%)

6(20%)

16(53.3%)

≤ 40

13(43.3%)

1(3.3%)

14(46.6%)

SERUM CREATININE (mg/dl)

> 1.2

7(23.3%)

3(10%)

10(33.3%)

≤ 1.2

16(53.3%)

4(13.3%)

20(66.6%)

SERUM SODIUM (mEq/l)

≥ 130

18(60%)

7(23.3%)

25(83.3%)

< 130

5(16.6%)

BILIRUBIN

≥ 2

5(16.6%)

3(10%)

8(26.6)

< 2

18(60%)

4(13.3%)

22(73.3)

TABLE NO 12: ETIOLOGY AND PATIENT OUTCOME (n=30)

ETIOLOGY

PATIENT ALIVE

n(%)

PATIENT DIED

n(%)

TOTAL

n(%)

P value

(95% CI)

INFECTIOUS

BACTERIAL

2(6.6%)

1(3.3%)

VIRAL

2(6.6%)

1(3.3)

3(10%)

1(3.3%)

PARASITIC

METABOLIC

20(66.6%)

3(10%)

23(76.6%)

TOXINS

ALCOHOL

2(6.6%)

SEPTIC

1(3.3%)

2(6.6%)

3(10%)

REFERENCES

•1. Modi A, Atam V, Jain N, Gutch M, Verma R. The etiological diagnosis and outcome in patients of acute febrile encephalopathy: a prospective observational study at tertiary care center. Neurol India. 2012 Apr;60(2):168–73.

• 2. Bhalla A, Suri V, Varma S, Sharma N, Mahi S, Singh P, et al. Acute febrile encephalopathy in adults from Northwest India. J Emerg Trauma Shock. 2010 Jul;3(3):220–4.

•3. Kothari VM, Karnad DR, Bichile LS.Tropical infections in the ICU.J Assoc Physicians India. 2006 Apr;54:291–8.

• 4. Morandi A, Pandharipande P, Trabucchi M, Rozzini R, Mistraletti G, Trompeo AC, et al. Understanding international differences in terminology for delirium and other types of acute brain dysfunction in critically ill patients. Intensive Care Med. 2008 Oct;34(10):1907–15.

• 5. Yeolekar ME, Trivedi TH. Febrile encephalopathy: challenges in management. J Assoc Physicians India. 2006 Nov;54:845–7.

Altered sensorium

https://madupusanthoshini82.blogspot.com/2023/08/a-45-yrs-old-male-patient-with-altered.html

https://vaishnavimaguluri.blogspot.com/2023/07/62y-male-with-pedal-edema-since-6.html

50F altered sensorium blog

https://manaswinibhootharaju153.blogspot.com/2023/02/88-yrs-old-female-came-to-casualty-with.html

https://srinithya27.blogspot.com/2023/02/70yr-old-male-with-altered-sensorium.html.

https://abhignya83.blogspot.com/2023/02/35-yr-old-male-with-altered-sensorium.html.

http://marisatejaswini.blogspot.com/2023/02/70f-with-altered-sensorium-secondary-to.html.

https://nehareddygaddam.blogspot.com/2022/10/80yr-male-with-altered-sensorium.html

https://manogna33.blogspot.com/2022/11/44-year-old-male.html

http://abhirambhashyakarla.blogspot.com/2022/11/a-case-of-78-year-old-female-with_25.html