Effects of the neurological wake-up test on clinical examination, intracranial pressure, brain metabolism and brain tissue oxygenation in severely brain-injured patients.docVIP

Helboketal.CriticalCare2012,16:R226 /content/16/6/R226 RESEARCH OpenAccess Effectsoftheneurologicalwake-upteston clinicalexamination,intracranialpressure,brain metabolismandbraintissueoxygenationin severelybrain-injuredpatients RaimundHelbok1,2*,PedroKurtz1,MichaelJSchmidt1,MorganRStuart1,LuisFernandez1,SanderEConnolly1, KiwonLee1,ErichSchmutzhard2,StephanAMayer1,JanClaassen1andNeerajBadjatia1,3* Abstract Introduction:Dailyinterruptionofsedation(IS)hasbeenimplementedin30to40%ofintensivecareunits worldwideandmayimproveoutcomeinmedicalintensivecarepatients.LittleisknownaboutthebenefitofISin acutelybrain-injuredpatients. Methods:Thisprospectiveobservationalstudywasperformedinaneuroscienceintensivecareunitinatertiary- careacademiccenter.Twentyconsecutiveseverelybrain-injuredpatientswithmultimodalneuromonitoringwere analyzedforlevelsofbrainlactate,pyruvateandglucose,intracranialpressure(ICP),cerebralperfusionpressure (CPP)andbraintissueoxygentension(PbtO2)duringIStrials. Results:Ofthe82trialdays,54IS-trialswereperformedasinterruptionofsedationandanalgesicswerenot consideredsafeon28days(34%).AnincreaseintheFOURScore(FullOutlineofUnResponsivenessscore)was observedin50%ofIS-trialsbyamedianofthree(twotofour)points.Detectionofanewneurologicdeficit occurredinonetrial(2%),andinone-thirdofIS-trialsthetrialhadtobestoppedduetoanICP-crisis(20 mmHg),agitationorsystemicdesaturation.InIS-trialsthathadtobeaborted,asignificantincreaseinICPand decreaseinPbtO2(P0.05),including67%withcriticalvaluesofPbtO220mmHg,atendencytobrainmetabolic distress(P0.07)wasobserved. Conclusions:Interruptionofsedationrevealednewrelevantclinicalinformationinonlyonetrialandalarge numberoftrialscouldnotbeperformedorhadtobestoppedduetosafetyissues.Weighingprosandconsof IS-trialsinpatientswithacutebraininjuryseemsimportantasrelatedsideeffectsmayovercometheclinical benefit. Introduction Dailyinterruptionofsedationtrials(IS-trials)havebeen Titratingsedativesandanalgesicstoachievetherightbal- implementedinmany