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The neurological wake-up test increases stress hormone levels in patients with severe traumatic brain injury
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurosurgery.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurosurgery.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurosurgery.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurosurgery.
2012 (English)In: Critical Care Medicine, ISSN 0090-3493, E-ISSN 1530-0293, Vol. 40, no 1, 216-222 p.Article 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.

Place, publisher, year, edition, pages
2012. Vol. 40, no 1, 216-222 p.
Keyword [en]
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: urn:nbn:se:uu:diva-168113DOI: 10.1097/CCM.0b013e31822d7dbdISI: 000298379800031OAI: oai:DiVA.org:uu-168113DiVA: diva2:491791
Available from: 2012-02-07 Created: 2012-02-06 Last updated: 2017-12-08Bibliographically approved
In thesis
1. The Neurological Wake-up Test in Neurocritical Care
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. 70 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 777
Keyword
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

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Skoglund, KarinEnblad, PerHillered, LarsMarklund, Niklas

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