“Wake Me Up before You Go-Go”. Drug, ‘Wham’, Scope, then Snooze. Can’t We do Better with Conscious Sedation for Endoscopy?

Byrne, Michael F.

doi:10.1155/2006/670754

Cited by 2 publications

(2 citation statements)

References 12 publications

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“…Midazolam use is not recommended for sedation because it precludes the ability to perform reliable, serial NWTs ( 105 ); it is associated with greater ICU length of stay, duration of mechanical ventilation, and delirium compared to propofol or dexmedetomidine ( 124 ); and is associated with dramatically prolonged time to awakening compared to propofol ( 125 – 128 ) and dexmedetomidine ( 129 , 130 ). Despite the numerous pitfalls of midazolam use, it remains one of the most common sedatives utilized in ICUs ( 3 ).…”

Section: Choice Of Sedativementioning

confidence: 99%

Neurologic Assessment of the Neurocritical Care Patient

Musick

Alberico

2021

Front. Neurol.

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Sedation is a ubiquitous practice in ICUs and NCCUs. It has the benefit of reducing cerebral energy demands, but also precludes an accurate neurologic assessment. Because of this, sedation is intermittently stopped for the purposes of a neurologic assessment, which is termed a neurologic wake-up test (NWT). NWTs are considered to be the gold-standard in continued assessment of brain-injured patients under sedation. NWTs also produce an acute stress response that is accompanied by elevations in blood pressure, respiratory rate, heart rate, and ICP. Utilization of cerebral microdialysis and brain tissue oxygen monitoring in small cohorts of brain-injured patients suggests that this is not mirrored by alterations in cerebral metabolism, and seldom affects oxygenation. The hard contraindications for the NWT are preexisting intracranial hypertension, barbiturate treatment, status epilepticus, and hyperthermia. However, hemodynamic instability, sedative use for primary ICP control, and sedative use for severe agitation or respiratory distress are considered significant safety concerns. Despite ubiquitous recommendation, it is not clear if additional clinically relevant information is gleaned through its use, especially with the contemporaneous utilization of multimodality monitoring. Various monitoring modalities provide unique and pertinent information about neurologic function, however, their role in improving patient outcomes and guiding treatment plans has not been fully elucidated. There is a paucity of information pertaining to the optimal frequency of NWTs, and if it differs based on type of injury. Only one concrete recommendation was found in the literature, exemplifying the uncertainty surrounding its utility. The most common sedative used and recommended is propofol because of its rapid onset, short duration, and reduction of cerebral energy requirements. Dexmedetomidine may be employed to facilitate serial NWTs, and should always be used in the non-intubated patient or if propofol infusion syndrome (PRIS) develops. Midazolam is not recommended due to tissue accumulation and residual sedation confounding a reliable NWT. Thus, NWTs are well-tolerated in selected patients and remain recommended as the gold-standard for continued neuromonitoring. Predicated upon one expert panel, they should be performed at least one time per day. Propofol or dexmedetomidine are the main sedative choices, both enabling a rapid awakening and consistent NWT.

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Section: Choice Of Sedativementioning

confidence: 99%

Neurologic Assessment of the Neurocritical Care Patient

Musick

Alberico

2021

Front. Neurol.

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“…In non-intubated brain injured patients, or with the development of PRIS, dexmedetomidine should be the primary sedative. Midazolam use is not recommended for sedation because it precludes the ability to perform reliable, serial NWTs (93); it is associated with greater ICU length of stay, duration of mechanical ventilation, and delirium compared to propofol or dexmedetomidine (109); and is associated with dramatically prolonged time to awakening compared to propofol (110)(111)(112)(113) and dexmedetomidine (114,115). Despite the numerous pitfalls of midazolam use, it remains one of the most common sedatives utilized in ICUs (3).…”

Section: Choice Of Sedativementioning

confidence: 99%

Neurologic Assessment of the Neurocritical Care Patient: The Neurologic Wake-Up Test

Musick¹,

Alberico²

2020

Preprint

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Sedation is a ubiquitous practice in ICUs and NCCUs. It has the benefit of reducing cerebral energy demands, but also precludes an accurate neurologic assessment. Because of this, sedation is intermittently stopped for the purposes of a neurologic assessment, which is termed a neurologic wake-up test (NWT). NWTs are considered to be the gold-standard in continued assessment of brain-injured patients under sedation. NWTs also produce an acute stress response that is accompanied by elevations in blood pressure, respiratory rate, heart rate, and ICP. Utilization of cerebral microdialysis and brain tissue oxygen monitoring indicates that this is not mirrored by alterations in overall cerebral metabolism, and seldom affects oxygenation. The hard contraindications for the NWT are preexisting intracranial hypertension, barbiturate treatment, status epilepticus, and hyperthermia. However, hemodynamic instability, sedative use for primary ICP control, and sedative use for severe agitation or respiratory distress are considered significant safety concerns. Despite ubiquitous recommendation, it is not clear if additional clinically relevant information is gleaned through its use, especially with the contemporaneous utilization of multimodality monitoring. Various monitoring modalities provide unique and pertinent information about neurologic function, however, their role in improving patient outcomes and guiding treatment plans has not been fully elucidated. There is a paucity of information pertaining to the optimal frequency of NWTs, and if it differs based on type of injury. Only one concrete recommendation was found in the literature, exemplifying the uncertainty surrounding its utility. The most common sedative used and recommended is propofol because of its rapid onset, short duration, and reduction of cerebral energy requirements. Dexmedetomidine may be employed to facilitate serial NWTs, and should always be used in the non-intubated patient or if propofol infusion syndrome (PRIS) develops. Midazolam is not recommended due to tissue accumulation and residual sedation confounding a reliable NWT. Thus, NWTs are well tolerated in most patients and remain recommended as the gold-standard for continued neuromonitoring. Predicated upon one expert panel, they should be performed at least one time per day. Propofol or dexmedetomidine are the main sedative choices, both enabling a rapid awakening and consistent NWT.

show abstract

“Wake Me Up before You Go-Go”. Drug, ‘Wham’, Scope, then Snooze. Can’t We do Better with Conscious Sedation for Endoscopy?

Cited by 2 publications

References 12 publications

Neurologic Assessment of the Neurocritical Care Patient

Neurologic Assessment of the Neurocritical Care Patient

Neurologic Assessment of the Neurocritical Care Patient: The Neurologic Wake-Up Test

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