Introduction:
The recovery of neurological status and mood following a major burn is slow and variable. Usually changes are transient and due to the injuries and medication to which the patient was exposed. Due to the difficulty in defining the diagnostic criteria, the non-convulsive status epilepticus (NCSE) is an entity difficult to identify, determine prevalence and outcome. It is probably underdiagnosed, associated with risk factors and does not have as benign evolution as previously thought.

Case report:
Male,15 years old,60% of the total body surface burned. In the emergency room intubation was required due to respiratory difficulty. The patient was tachycardic, without other hemodynamic changes, ECG 15. Urinary output 0cc/2h. Medical history: 33 weeks premature, respiratory distress syndrome requiring hospitalization at 1 month of age for sepsis, possible cognitive deficit. In the burn ICU, he remained sedated and ventilated; noradrenaline was needed for tension stabilization. At the 2nd post-burn day, he developed acute renal injury with anuria in the context of hypovolemic shock and severe metabolic acidosis – renal substitution was initiated and maintained until the 19th day. Surgical interventions and antibiotics were necessary. He was extubated at the 45th day, presenting apathetic and not very cooperative, which was attributed to residual sedation and difficulty in accepting the current state of health. On the 7th day after extubation, psychiatry prescribed fluoxetine. At the 8th day, developed a generalized tonic-clonic convulsion lasting a few seconds that reverted spontaneously, without desaturation or hemodynamic changes. EEG - focal non-convulsive disease: clinical manifestations are subtle: decreased responsiveness and apathetic facial expression. Starts levetiracetam. From that day, he had no further episodes and showed great improvement of the neurological status. He was discharged from the burn ICU after 100 days of hospitalization, neurological status similar to his usual, with the indication for conducting a CT scan for etiological study. 

Conclusion:
Assessment of the neurological status of a patient after 45 days of sedation,who was in shock with multiorgan dysfunction and with a history of possible cognitive deficit is a challenge.This case report draws our attention to the existence of NCSE and to the high level of suspicion needed for diagnosis. In patients with risk factors,we should be watchful,once early treatment seems important for recovery, to prevent long-term sequelae.

12 / Challenges in the assessment of post-extubation neurological status in an Intensive Care Unit (ICU): case report of a major burn patient