Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on sleep in brain health

LIVE: Thursday 2nd May 2024, 18:00-19:30 (CEST)

Quality sleep is essential for health. But what happens to our brains when sleep patterns are disturbed? Join our experts to explore the interplay between sleep disruption and neurological diseases, and the questions that you need to be asking your patients to help you prevent the harmful effects of sleep deprivation.
ADVANCED SEARCH
Log in
Top
Neurocritical Care
Published in: Neurocritical Care 2/2009

01-10-2009 | Original Article

Effects of the Neurological Wake-Up Test on Intracranial Pressure and Cerebral Perfusion Pressure in Brain-Injured Patients

Authors: Karin Skoglund, Per Enblad, Niklas Marklund

Published in: Neurocritical Care | Issue 2/2009

Login to get access

Abstract

Objective

To evaluate the effects of the neurological “wake-up test” (NWT), defined as interruption of continuous propofol sedation and evaluation of the patient’s level of consciousness, on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in patients with severe subarachnoid hemorrhage (SAH) or traumatic brain injury (TBI).

Methods

A total of 127 NWT procedures in 21 severely brain-injured adult patients with either TBI (n = 12) or SAH (n = 9) were evaluated. ICP and CPP levels prior to, during and after the NWT procedure were recorded.

Results

During the NWT, ICP increased from 13.4 ± 6 mmHg at baseline to 22.7 ± 12 (P < 0.05) and the CPP increased from 75.6 ± 11 to 79.1 ± 21  mmHg (P < 0.05) in TBI patients. Eight patients showed a reduced CPP during the NWT due to increased ICP. In SAH patients, ICP increased from 10.6 ± 5 to 16.8 ± 8 mmHg (P < 0.05) and the CPP increased from 76.9 ± 13 to 84.6 ± 15 mmHg (P < 0.05).

Conclusion

When continuous propofol sedation was interrupted and NWT was performed in severely brain-injured patients, the mean ICP and CPP levels were modestly increased. A subset of patients showed more pronounced changes. To date, the role of the NWT in the neurointensive care of TBI and SAH patients is unclear. Although the NWT is safe in the majority of patients and may provide useful clinical information about the patient’s level of consciousness, alternate monitoring methods are suggested in patients showing marked ICP and/or CPP changes during NWT.
Literature
1.
Becker DP, Miller JD, Ward JD, Greenberg RP, Young HF, Sakalas R. The outcome from severe head injury with early diagnosis and intensive management. J Neurosurg. 1977;47(4):491–502.PubMedCrossRef
2.
Elf K, Nilsson P, Enblad P. Outcome after traumatic brain injury improved by an organized secondary insult program and standardized neurointensive care. Crit Care Med. 2002;30(9):2129–34.PubMedCrossRef
3.
Grande PO, Naredi S. Clinical studies in severe traumatic brain injury: a controversial issue. Intensive Care Med. 2002;28(5):529–31.PubMedCrossRef
4.
Patel HC, Menon DK, Tebbs S, Hawker R, Hutchinson PJ, Kirkpatrick PJ. Specialist neurocritical care and outcome from head injury. Intensive Care Med. 2002;28(5):547–53.PubMedCrossRef
5.
Ryttlefors M, Howells T, Nilsson P, Ronne-Engstrom E, Enblad P. Secondary insults in subarachnoid hemorrhage: occurrence and impact on outcome and clinical deterioration. Neurosurgery. 2007;61(4):704–14.PubMedCrossRef
6.
Allen CH, Ward JD. An evidence-based approach to management of increased intracranial pressure. Crit Care Clin. 1998;14(3):485–95.PubMedCrossRef
7.
Smith M. Monitoring intracranial pressure in traumatic brain injury. Anesth Analg. 2008;106(1):240–8.PubMedCrossRef
8.
Young JS, Blow O, Turrentine F, Claridge JA, Schulman A. Is there an upper limit of intracranial pressure in patients with severe head injury if cerebral perfusion pressure is maintained? Neurosurg Focus. 2003;15(6):E2.PubMedCrossRef
9.
Citerio G, Cormio M. Sedation in neurointensive care: advances in understanding and practice. Curr Opin Crit Care. 2003;9(2):120–6.PubMedCrossRef
10.
Rhoney DH, Parker D Jr. Use of sedative and analgesic agents in neurotrauma patients: effects on cerebral physiology. Neurol Res. 2001;23(2–3):237–59.PubMedCrossRef
11.
Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale 3. Lancet. 1974;2(7872):81–4.PubMedCrossRef
12.
Starmark JE, Stalhammar D, Holmgren E. The Reaction Level Scale (RLS85). Manual and guidelines. Acta Neurochir (Wien). 1988;91(1–2):12–20.CrossRef
13.
Maas AI, Stocchetti N, Bullock R. Moderate and severe traumatic brain injury in adults. Lancet Neurol. 2008;7(8):728–41.PubMedCrossRef
14.
Corral L, Ventura JL, Herrero JI, et al. Improvement in GOS and GOSE scores 6 and 12 months after severe traumatic brain injury. Brain Inj. 2007;21(12):1225–31.PubMedCrossRef
15.
Sessler CN, Jo GM, Ramsay MA. Evaluating and monitoring analgesia and sedation in the intensive care unit. Crit Care 2008;12(Suppl 3):S2.
16.
Cesarini KG, Hardemark HG, Persson L. Improved survival after aneurysmal subarachnoid hemorrhage: review of case management during a 12-year period. J Neurosurg. 1999;90(4):664–72.PubMedCrossRef
17.
Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, Joint Section on Neurotrauma and Critical Care, AANS/CNS, Bratton SL, Chestnut RM, Ghajar J, McConnell Hammond FF, Harris OA, Hartl R, Manley GT, Nemecek A, Newell DW, Rosenthal G, Schouten J, Shutter L, Timmons SD, Ullman JS, Videtta W, Wilberger JE, Wright DW. Guidelines for the management of severe traumatic brain injury. J Neurotrauma. 2007;24(Suppl 1):S1–106.
18.
Strömgren K, Marklund N. The use of neurological examination in severely brain-injured patients—its use in Scandinavian neurointensive care units and the influence on ICP and CPP. Presented at the 7th Quadrennial Congress of the European Association of Neuroscience Nurses, Copenhagen, Denmark, 19–21 May 2003.
19.
Juul N, Morris GF, Marshall SB, Marshall LF. Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head injury. The Executive Committee of the International Selfotel Trial. J Neurosurg. 2000;92(1):1–6.PubMedCrossRef
20.
Maas AI, Murray G, Henney HIII, et al. Efficacy and safety of dexanabinol in severe traumatic brain injury: results of a phase III randomised, placebo-controlled, clinical trial. Lancet Neurol. 2006;5(1):38–45.PubMedCrossRef
21.
Morris GF, Juul N, Marshall SB, Benedict B, Marshall LF. Neurological deterioration as a potential alternative endpoint in human clinical trials of experimental pharmacological agents for treatment of severe traumatic brain injuries. Executive Committee of the International Selfotel Trial. Neurosurgery. 1998;43(6):1369–72.PubMedCrossRef
22.
Reilly P. Management of intracranial pressure and cerebral perfusion. In: Reilly P, Bullock R, editors. Head injury- pathophysiology and management of severe closed injury. London: Chapman & Hall; 1997. p. 385–407.
23.
Carrasco G. Instruments for monitoring intensive care unit sedation. Crit Care. 2000;4(4):217–25.PubMedCrossRef
24.
Girard TD, Kress JP, Fuchs BD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial 1. Lancet. 2008;371(9607):126–34.PubMedCrossRef
25.
Ostermann ME, Keenan SP, Seiferling RA, Sibbald WJ. Sedation in the intensive care unit: a systematic review. JAMA. 2000;283(11):1451–9.PubMedCrossRef
26.
27.
Blamoun J, Alfakir M, Rella ME et al. Efficacy of an expanded ventilator bundle for the reduction of ventilator-associated pneumonia in the medical intensive care unit. Am J Infect Control. 2009;37(2):172–5.PubMedCrossRef
28.
Resar R, Pronovost P, Haraden C, Simmonds T, Rainey T, Nolan T. Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. Jt Comm J Qual Patient Saf. 2005;31(5):243–8.PubMed
29.
Youngquist P, Carroll M, Farber M, et al. Implementing a ventilator bundle in a community hospital. Jt Comm J Qual Patient Saf. 2007;33(4):219–25.PubMed
30.
Balestreri M, Czosnyka M, Hutchinson P, et al. Impact of intracranial pressure and cerebral perfusion pressure on severe disability and mortality after head injury. Neurocrit Care. 2006;4(1):8–13.PubMedCrossRef
31.
Dimopoulou I, Tsagarakis S, Kouyialis AT, et al. Hypothalamic-pituitary-adrenal axis dysfunction in critically ill patients with traumatic brain injury: incidence, pathophysiology, and relationship to vasopressor dependence and peripheral interleukin-6 levels. Crit Care Med. 2004;32(2):404–8.PubMedCrossRef
32.
Elf K, Nilsson P, Ronne-Engstrom E, Howells T, Enblad P. Cerebral perfusion pressure between 50 and 60 mmHg may be beneficial in head-injured patients: a computerized secondary insult monitoring study. Neurosurgery. 2005;56(5):962–71.PubMed
33.
Skoglund K, Enblad P, Marklund N. Interruption of continuous sedation increases cortisol and ACTH levels in patients with severe Traumatic brain injury. Presented at the 10th Quadrennial Congress of the World Federation of Neuroscience Nurses, Toronto, Canada, 23–27 May 2009.
34.
White H, Venkatesh B. Cerebral perfusion pressure in neurotrauma: a review. Anesth Analg. 2008;107(3):979–88.PubMedCrossRef
35.
Deogaonkar A, Gupta R, DeGeorgia M, et al. Bispectral Index monitoring correlates with sedation scales in brain-injured patients. Crit Care Med. 2004;32(12):2403–6.PubMedCrossRef
36.
Anglen JO, Luber K, Park T. The effect of femoral nailing on cerebral perfusion pressure in head-injured patients. J Trauma. 2003;54(6):1166–70.PubMedCrossRef
37.
Gemma M, Tommasino C, Cerri M, Giannotti A, Piazzi B, Borghi T. Intracranial effects of endotracheal suctioning in the acute phase of head injury. J Neurosurg Anesthesiol. 2002;14(1):50–4.PubMedCrossRef
38.
Kerr ME, Weber BB, Sereika SM, Darby J, Marion DW, Orndoff PA. Effect of endotracheal suctioning on cerebral oxygenation in traumatic brain-injured patients. Crit Care Med. 1999;27(12):2776–81.PubMedCrossRef
39.
Kerwin AJ, Croce MA, Timmons SD, Maxwell RA, Malhotra AK, Fabian TC. Effects of fiberoptic bronchoscopy on intracranial pressure in patients with brain injury: a prospective clinical study. J Trauma. 2000;48(5):878–82.PubMedCrossRef
40.
Bruder N, Stordeur JM, Ravussin P, et al. Metabolic and hemodynamic changes during recovery and tracheal extubation in neurosurgical patients: immediate versus delayed recovery. Anesth Analg. 1999;89(3):674–8.PubMedCrossRef
41.
Bruder N, Pellissier D, Grillot P, Gouin F. Cerebral hyperemia during recovery from general anesthesia in neurosurgical patients. Anesth Analg. 2002;94(3):650–4.PubMedCrossRef
42.
Czosnyka M, Smielewski P, Piechnik S, et al. Hemodynamic characterization of intracranial pressure plateau waves in head-injury patients. J Neurosurg. 1999;91(1):11–9.PubMedCrossRef
43.
Kirkness CJ, Burr RL, Cain KC, Newell DW, Mitchell PH. Relationship of cerebral perfusion pressure levels to outcome in traumatic brain injury. Acta Neurochir Suppl. 2005;95:13–6.PubMedCrossRef
44.
Kroppenstedt SN, Kern M, Thomale UW, Schneider GH, Lanksch WR, Unterberg AW. Effect of cerebral perfusion pressure on contusion volume following impact injury. J Neurosurg. 1999;90(3):520–6.PubMedCrossRef
45.
Lang EW, Czosnyka M, Mehdorn HM. Tissue oxygen reactivity and cerebral autoregulation after severe traumatic brain injury. Crit Care Med. 2003;31(1):267–71.PubMedCrossRef
46.
Nordstrom CH. Assessment of critical thresholds for cerebral perfusion pressure by performing bedside monitoring of cerebral energy metabolism. Neurosurg Focus. 2003;15(6):E5.PubMedCrossRef
47.
Steiner LA, Andrews PJ. Monitoring the injured brain: ICP and CBF. Br J Anaesth. 2006;97(1):26–38.PubMedCrossRef
48.
Tisdall MM, Smith M. Multimodal monitoring in traumatic brain injury: current status and future directions. Br J Anaesth. 2007;99(1):61–7.PubMedCrossRef
49.
Helmy A, Vizcaychipi M, Gupta AK. Traumatic brain injury: intensive care management. Br J Anaesth. 2007;99(1):32–42.PubMedCrossRef
50.
Valadka AB, Robertson CS. Surgery of cerebral trauma and associated critical care. Neurosurgery. 2007;61(1 Suppl):203–20.PubMed
Metadata
Title
Effects of the Neurological Wake-Up Test on Intracranial Pressure and Cerebral Perfusion Pressure in Brain-Injured Patients
Authors
Karin Skoglund
Per Enblad
Niklas Marklund
Publication date
01-10-2009
Publisher
Humana Press Inc
Published in
Neurocritical Care / Issue 2/2009
Print ISSN: 1541-6933
Electronic ISSN: 1556-0961
DOI
https://doi.org/10.1007/s12028-009-9255-3

Other articles of this Issue 2/2009

Neurocritical Care 2/2009 Go to the issue

Practical Pearl

False Positive CT Angiography in Brain Death

Review Article

Pitfalls in the Diagnosis of Brain Death

Original Article

Quantitative EEG Correlates of Low Cerebral Perfusion in Severe Stroke

Editorial

Is Daily Awakening Always Safe in Severely Brain Injured Patients?

Original Article

Feasibility of NIRS in the Neurointensive Care Unit: A Pilot Study in Stroke Using Physiological Oscillations

Original Article

Diabetes Mellitus Increases Risk of Vasospasm Following Aneurysmal Subarachnoid Hemorrhage Independent of Glycemic Control