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Skoglund, Karin
Publications (6 of 6) Show all publications
Skoglund, K., Hillered, L., Purins, K., Tsitsopoulos, P. P., Flygt, J., Engquist, H., . . . Marklund, N. (2014). The Neurological Wake-up Test Does not Alter Cerebral Energy Metabolism and Oxygenation in Patients with Severe Traumatic Brain Injury. Neurocritical Care, 20(3), 413-426
Open this publication in new window or tab >>The Neurological Wake-up Test Does not Alter Cerebral Energy Metabolism and Oxygenation in Patients with Severe Traumatic Brain Injury
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2014 (English)In: Neurocritical Care, ISSN 1541-6933, E-ISSN 1556-0961, Vol. 20, no 3, p. 413-426Article in journal (Refereed) Published
Abstract [en]

The neurological wake-up test (NWT) is used to monitor the level of consciousness in patients with traumatic brain injury (TBI). However, it requires interruption of sedation and may elicit a stress response. We evaluated the effects of the NWT using cerebral microdialysis (MD), brain tissue oxygenation (PbtiO2), jugular venous oxygen saturation (SjvO(2)), and/or arterial-venous difference (AVD) for glucose, lactate, and oxygen in patients with severe TBI. Seventeen intubated TBI patients (age 16-74 years) were sedated using continuous propofol infusion. All patients received intracranial pressure (ICP) and cerebral perfusion pressure (CPP) monitoring in addition to MD, PbtiO2 and/or SjvO(2). Up to 10 days post-injury, ICP, CPP, PbtiO2 (51 NWTs), MD (49 NWTs), and/or SjvO(2) (18 NWTs) levels during propofol sedation (baseline) and NWT were compared. MD was evaluated at a flow rate of 1.0 mu L/min (28 NWTs) or the routine 0.3 mu L/min rate (21 NWTs). The NWT increased ICP and CPP levels (p < 0.05). Compared to baseline, interstitial levels of glucose, lactate, pyruvate, glutamate, glycerol, and the lactate/pyruvate ratio were unaltered by the NWT. Pathological SjvO(2) (< 50 % or > 71 %; n = 2 NWTs) and PbtiO2 (< 10 mmHg; n = 3 NWTs) values were rare at baseline and did not change following NWT. Finally, the NWT did not alter the AVD of glucose, lactate, or oxygen. The NWT-induced stress response resulted in increased ICP and CPP levels although it did not negatively alter focal neurochemistry or cerebral oxygenation in TBI patients.

Keywords
Traumatic brain injury, Cerebral microdialysis, Brain tissue oxygenation, Jugular venous oxygenation, Neurological wake-up test, Brain energy metabolism, Interruption of sedation
National Category
Neurosciences Neurology
Identifiers
urn:nbn:se:uu:diva-228469 (URN)10.1007/s12028-013-9876-4 (DOI)000337092900010 ()
Available from: 2014-07-15 Created: 2014-07-15 Last updated: 2022-01-28Bibliographically approved
Skoglund, K. (2012). The Neurological Wake-up Test in Neurocritical Care. (Doctoral dissertation). Uppsala: Acta Universitatis Upsaliensis
Open this publication in new window or tab >>The Neurological Wake-up Test in Neurocritical Care
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The neurological wake-up test, NWT, is a clinical monitoring tool that can be used to evaluate the level of consciousness in patients with traumatic brain injury (TBI) and subarachnoid haemorrhage (SAH) during neurocritical care (NCC). Since patients with severe TBI or SAH are often treated with mechanical ventilation and sedation, the NWT requires that the continuous sedation is interrupted. However, interruption of continuous sedation may induce a stress response and the use of the NWT in NCC is controversial.

The effects of the NWT on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) were evaluated in 21 patients with TBI or SAH. Compared to baseline when the patients were sedated with continuous propofol sedation, the NWT resulted in increased ICP and CPP (p<0.05). Next, the effects of the NWT on the stress hormones adrenocorticotrophic hormone (ACTH), cortisol, epinephrine and norepinephrine were evaluated in 24 patients. Compared to baseline, the NWT caused a mild stress response resulting in increased levels of all evaluated stress hormones (p<0.05). To compare the use of routine NCC monitoring tools, the choice of sedation and analgesia and the frequency of NWT in Scandinavian NCC units, a questionnaire was used. The results showed that all 16 Scandinavian NCC units routinely use ICP and CPP monitoring and propofol and midazolam were primary choices for patient sedation in an equal number of NCC units. In 2009, the NWT was not routinely used in eight NCC units whereas others used the test up to six times daily.

Finally, intracerebral microdialysis (MD), brain tissue oxygenation (PbtiO2) and jugular bulb oxygenation (SjvO2) were used in 17 TBI patients to evaluate the effect of the NWT procedure on focal neurochemistry and cerebral oxygenation. The NWT did not negatively alter interstitial markers of energy metabolism or cerebral oxygenation.

In conclusion, the NWT induced a mild stress response in patients with TBI or SAH that did not result in a detectable, significant secondary insult to the injured brain. These results suggest that the NWT may safely be used as a clinical monitoring tool in the NCC of severe TBI and SAH in a majority of patients.

 

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2012. p. 70
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 777
Keywords
Intracranial pressure, Cerebral perfusion pressure, Propofol sedation, Wake-up test, stress hormones; intracerebral microdialysis, brain tissue oxygenation, jugular venous oxygenation
National Category
Medical and Health Sciences
Research subject
Neurosurgery
Identifiers
urn:nbn:se:uu:diva-172798 (URN)978-91-554-8374-6 (ISBN)
Public defence
2012-05-31, Robergsalen, ing 40, vån 4, Akademiska sjukhuset, Uppsala, 09:15 (Swedish)
Opponent
Supervisors
Available from: 2012-05-09 Created: 2012-04-16 Last updated: 2012-08-01Bibliographically approved
Skoglund, K., Enblad, P., Hillered, L. & Marklund, N. (2012). The neurological wake-up test increases stress hormone levels in patients with severe traumatic brain injury. Critical Care Medicine, 40(1), 216-222
Open this publication in new window or tab >>The neurological wake-up test increases stress hormone levels in patients with severe traumatic brain injury
2012 (English)In: Critical Care Medicine, ISSN 0090-3493, E-ISSN 1530-0293, Vol. 40, no 1, p. 216-222Article in journal (Refereed) Published
Abstract [en]

Objectives: The "neurological wake-up test" is needed to evaluate the level of consciousness in patients with severe traumatic brain injury. However, the neurological wake-up test requires interruption of continuous sedation and may induce a stress response and its use in neurocritical care is controversial. We hypothesized that the neurological wake-up test induces an additional biochemical stress response in patients with severe traumatic brain injury.

Patients: Twenty-four patients who received continuous propofol sedation and mechanical ventilation after moderate to severe traumatic brain injury (Glasgow Coma Scale score <= 8; patient age 18-71 yrs old) were analyzed. Exclusion criteria were age <18 yrs old, ongoing pentobarbital infusion, or markedly increased intracranial pressure on interruption of continuous sedation.

Design: Single-center prospective study. During postinjury days 1-8, 65 neurological wake-up tests were evaluated. Adrenocorticotrophic hormone, epinephrine, and norepinephrine levels in plasma and cortisol levels in saliva were analyzed at baseline (during continuous intravenous propofol sedation) and during neurological wake-up test. Data are presented using medians and 25th and 75th percentiles.

Setting: The study was performed in a university hospital neurocritical care unit.

Interventions: None.

Measurements and Main Results: At baseline, adrenocorticotrophic hormone and cortisol levels were 10.6 (6.0-19.4) ng/L and 16.0 (10.7-31.8) nmol/L, respectively. Immediately after the neurological wake-up test, adrenocorticotrophic hormone levels increased to 20.5 (11.1-48.4) ng/L (p < .05) and cortisol levels in saliva increased to 24.0 (12.3-42.5) nmol/L (p < .05). The plasma epinephrine and norepinephrine levels increased from a baseline of 0.3 (0.3-0.6) and 1.6 (0.9-2.3) nmol/L, respectively, to 0.75 (0.3-1.4) and 2.8 (1.28-3.58) nmol/L, respectively (both p < .05).

Conclusions: The neurological wake-up test induces a biochemical stress response in patients with severe traumatic brain injury. The clinical importance of this stress response remains to be established but should be considered when deciding the frequency and use of the neurological wake-up test during neurocritical care.

Keywords
ACTH, catecholamines, cerebral perfusion pressure (CPP), cortisol, epinephrine, intracranial pressure (ICP), neurological wake-up test, norepinephrine, propofol, sedation
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-168113 (URN)10.1097/CCM.0b013e31822d7dbd (DOI)000298379800031 ()
Available from: 2012-02-07 Created: 2012-02-06 Last updated: 2017-12-08Bibliographically approved
Skoglund, K., Enblad, P., Hillered, L. & Marklund, N. (2012). Wake-up test and stress hormone levels in patients with brain injury: A focus on mechanisms involved: Reply [Letter to the editor]. Critical Care Medicine, 40(6), 2002-2003
Open this publication in new window or tab >>Wake-up test and stress hormone levels in patients with brain injury: A focus on mechanisms involved: Reply
2012 (English)In: Critical Care Medicine, ISSN 0090-3493, E-ISSN 1530-0293, Vol. 40, no 6, p. 2002-2003Article in journal, Letter (Refereed) Published
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-176530 (URN)10.1097/CCM.0b013e3182515055 (DOI)000304335600068 ()
Available from: 2012-06-20 Created: 2012-06-20 Last updated: 2017-12-07Bibliographically approved
Skoglund, K., Enblad, P. & Marklund, N. Monitoring and sedation differences in the management of severe head injury and subarachnoid hemorrhage among neurocritical care centers..
Open this publication in new window or tab >>Monitoring and sedation differences in the management of severe head injury and subarachnoid hemorrhage among neurocritical care centers.
(English)Article in journal (Refereed) Submitted
Keywords
wake-up test, sedation, monitoring, traumatic brain injury, subarachnoid haemorrhage
National Category
Clinical Medicine
Identifiers
urn:nbn:se:uu:diva-173428 (URN)
Available from: 2012-04-24 Created: 2012-04-24 Last updated: 2012-08-01Bibliographically approved
Skoglund, K., Hillered, L., Tsitsopoulos, P., Engquist, H., Purins, K., Lewén, A., . . . Marklund, N.The neurological wake-up test does not negatively influence brain oxygentaion and interstitial markers of cerebral energy metabolism in patients with severe traumatic brain injury.
Open this publication in new window or tab >>The neurological wake-up test does not negatively influence brain oxygentaion and interstitial markers of cerebral energy metabolism in patients with severe traumatic brain injury
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(English)Manuscript (preprint) (Other academic)
Keywords
Traumatic brain injury, intracerebral microdialysis, brain tissue oxygenation, jugular venous oxygenation, neurological wake up test
National Category
Clinical Medicine
Identifiers
urn:nbn:se:uu:diva-173430 (URN)
Available from: 2012-04-24 Created: 2012-04-24 Last updated: 2012-11-14
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