Abstract
The most fundamental clinical monitoring tool in traumatic brain injury (TBI) patients is the repeated clinical examination. In the severe TBI patient treated by continuous sedation in a neurocritical care (NCC) unit, sedation interruption is required to enable a clinical evaluation (named the neurological wake-up test; NWT) assessing the level of consciousness, pupillary diameter and reactivity to light, and presence of focal neurological deficits. There is a basic conflict regarding the NWT in the NCC setting; can the clinical information obtained by the NWT justify the risk of inducing a stress response in a severe TBI patient? Furthermore, in the presence of advanced multimodal monitoring and neuroimaging, is the NWT necessary to identify important clinical alterations? In studies of severe TBI patients, the NWT was consistently shown to induce a stress reaction including brief increases in intracranial pressure (ICP) and changes in cerebral perfusion pressure (CPP). However, it has not been established whether these short-lived ICP and CPP changes are detrimental to the injured brain. Daily interruption of sedation is associated with a reduced ventilator time, shorter hospital stay and reduced mortality in many studies of general intensive care unit patients, although such clinical benefits have not been firmly established in TBI. To date, there is no consensus on the use of the NWT among NCC units and systematic studies are scarce. Thus, additional studies evaluating the role of the NWT in clinical decision-making are needed. Multimodal NCC monitoring may be an adjunct in assessing in which TBI patients the NWT can be safely performed. At present, the NWT remains the golden standard for clinical monitoring and detection of neurological changes in NCC and could be considered in TBI patients with stable baseline ICP and CPP readings. The focus of the present review is an overview of the existing literature on the role of the NWT as a clinical monitoring tool for severe TBI patients.
Highlights
Intense clinical monitoring is an integral part of the management or traumatic brain injury (TBI) patients
Since there is no clear-cut evidence for a clinical benefit of sedation interruption in TBI patients, what other possible indications for the NWT are there? In particular, what additional information is sought by the NWT in the sedated and monitored TBI patient? The NWT is not mentioned in available TBI guidelines [13], and the use of the NWT may vary considerably among neurocritical care (NCC) centers
This study provides an additional argument that the NWT causes a stress response, which is mild in the majority of TBI patients
Summary
Intense clinical monitoring is an integral part of the management or traumatic brain injury (TBI) patients. A Wake-up Test in the NCC of TBI Patients or increased brain swelling [1, 2] stressing the importance of repeated clinical evaluations. The entity “talk-and-die” was coined [3], describing individuals in whom the severity of the initial, primary injury was insufficient to explain the poor outcome and that the occurrence of secondary, and presumably preventable and “avoidable,” factors resulted in the fatal exacerbation of the disease These findings prompted increased awareness and improved organization of TBI care, aided by the standardization of the neurological assessment through the introduction of the Glasgow Coma Scale (GCS) score in 1974 [4]. Clinical examinations in NCC for severe TBI are controversial since they pose a dilemma—while sedation interruption is needed for the important neurological evaluation, an undesired stress response is commonly elicited. For the purpose of this review, medical databases (Medline, Scopus, and PsychINFO) were searched using the terms TBI, or any combination of brain or head trauma/injury, together with wake-up test, SBT, SAT, and/ or lightening/interruption of sedation
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