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The neurological wake-up test increases stress hormone levels in patients with severe traumatic brain injury

Skoglund, Karin; Enblad, Per; Hillered, Lars and Marklund, Niklas LU (2012) In Critical Care Medicine 40(1). p.22-216
Abstract

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... (More)

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.

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publication status
published
keywords
Adolescent, Adrenocorticotropic Hormone, Adult, Aged, Brain Injuries, Deep Sedation, Epinephrine, Female, Glasgow Coma Scale, Humans, Hydrocortisone, Male, Middle Aged, Neurologic Examination, Norepinephrine, Prospective Studies, Saliva, Stress, Physiological, Young Adult, Journal Article, Research Support, Non-U.S. Gov't
in
Critical Care Medicine
volume
40
issue
1
pages
22 - 216
publisher
Lippincott Williams & Wilkins
external identifiers
  • scopus:84055190016
ISSN
1530-0293
DOI
10.1097/CCM.0b013e31822d7dbd
language
English
LU publication?
no
id
71bcb511-fc9b-4697-923a-c3f564368ee0
date added to LUP
2016-12-12 15:31:13
date last changed
2017-11-19 04:35:54
@article{71bcb511-fc9b-4697-923a-c3f564368ee0,
  abstract     = {<p>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.</p><p>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 &lt;18 yrs old, ongoing pentobarbital infusion, or markedly increased intracranial pressure on interruption of continuous sedation.</p><p>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.</p><p>SETTING: The study was performed in a university hospital neurocritical care unit.</p><p>INTERVENTIONS: None.</p><p>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 &lt; .05) and cortisol levels in saliva increased to 24.0 (12.3-42.5) nmol/L (p &lt; .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 &lt; .05).</p><p>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.</p>},
  author       = {Skoglund, Karin and Enblad, Per and Hillered, Lars and Marklund, Niklas},
  issn         = {1530-0293},
  keyword      = {Adolescent,Adrenocorticotropic Hormone,Adult,Aged,Brain Injuries,Deep Sedation,Epinephrine,Female,Glasgow Coma Scale,Humans,Hydrocortisone,Male,Middle Aged,Neurologic Examination,Norepinephrine,Prospective Studies,Saliva,Stress, Physiological,Young Adult,Journal Article,Research Support, Non-U.S. Gov't},
  language     = {eng},
  number       = {1},
  pages        = {22--216},
  publisher    = {Lippincott Williams & Wilkins},
  series       = {Critical Care Medicine},
  title        = {The neurological wake-up test increases stress hormone levels in patients with severe traumatic brain injury},
  url          = {http://dx.doi.org/10.1097/CCM.0b013e31822d7dbd},
  volume       = {40},
  year         = {2012},
}