The neurological wake-up test in severe pediatric traumatic brain injury: a long term, single-center experience.

Objectives: To describe the use and outcomes of the neurological wake-up test (NWT) in pediatric severe traumatic brain injury (pTBI). Design: Retrospective single-center observational cohort study. Setting: Medical-surgical tertiary pediatric intensive care unit (PICU) in a university medical center and Level 1 Trauma Center. Patients: Children younger than 18 years with severe TBI [i.e., Glasgow Coma Scale (GCS) of ≤8] admitted between January 2010 and December 2020. Subjects with non-traumatic brain injury were excluded. Measurements and main results: Of 168 TBI patients admitted, 36 (21%) met the inclusion criteria. Median age was 8.5 years [2 months to 16 years], 5 patients were younger than 6 months. Median initial Glasgow Coma Scale (GCS) and Glasgow Motor Scale (GMS) was 6 [3-8] and 3 [1-5]. NWTs were initiated in 14 (39%) patients, with 7 (50%) labelled as successful. Fall from a height was the underlying injury mechanism in those seven. NWT-failure occurred in patients admitted after traffic accidents. Sedation use in both NWT-subgroups (successful vs. failure) was comparable. Cause of NWT-failure was non-arousal (71%) or severe agitation (29%). Subjects with NWT failure subsequently had radiological examination (29%), repeat NWT (43%), continuous interruption of sedation (14%) or intracranial pressure (ICP) monitoring (14%). The primary reason for not doing NWTs was intracranial hypertension in 59%. Compared to the NWT-group, the non-NWT group had a higher PRISM III score (18.9 vs. 10.6), lower GCS/GMS at discharge, more associated trauma, and circulatory support. Nine patients (25%) died during their PICU admission, none of them had an NWT. Conclusion: We observed limited use of NWTs in pediatric severe TBI. Patients who failed the NWT were indistinguishable from those without NWT. Both groups were more severely affected compared to the NWT successes. Therefore, our results may indicate that only a select group of severe pTBI patients qualify for the NWT.

Neuromuscular Monitoring and Wake-Up Test During Scoliosis Surgery.

A typical spine is straight and symmetrical, with all of the vertebrae facing forward when viewed from the posterior. Scoliosis is a term used to describe a lateral deviation of the spine's normal vertical line that is greater than 10° on an X-ray. More severe curves are sometimes accompanied by medical issues such as increased back discomfort and cardiorespiratory difficulties along with the cosmetic components of the deformity. The test for spinal cord integrity prior to the widespread adoption of intraoperative neurophysiologic monitoring (IOM) was the wake-up test. In this article, we review the challenges faced by anesthesiologists and surgeons during intraoperative monitoring and the importance of clinical assessment of surgical outcomes.

The effect of dexmedetomidine on wake-up test quality when muscle relaxants are not used: A randomized control trial.

Background and Aims: Stagnara wake-up test is a simple reproducible neuromonitoring method during spinal surgery which replaces the evoked potential monitoring in the absence of neuromonitoring facilities. Dexmedetomidine (DEX) effect on the intraoperative wake-up test is still unclear. The present study was conducted to evaluate the effectiveness of DEX on the quality of wake-up test during spinal correction surgery. Methods: A randomized controlled study was carried out over 62 patients randomized into two equal groups planned for elective minimally invasive corrective spine surgery. Instead of atracurium administration in the control group, patients in the experimental group were administered titrated continuous intravenous infusion of DEX at a dose of 0.2-0.7 µg/kg/hour. Lidocaine 2% spray around the vocal cords was done in both the groups to facilitate toleration of the endotracheal tube. Results: The DEX group showed statistically significant longer duration and better quality of the wake-up test. Statistically significant better haemodynamic state, a lower amount of intraoperative sedatives and higher amount of intraoperative analgesics were also evident in the DEX group. The postoperative Ramsay sedation scale was significantly lower in the DEX group just after extubation. Conclusion: The DEX use has shown an improving effect on the wake-up test quality, with slightly prolonged wake-up time. The present work supports the use of DEX as an adjuvant drug alleviating the need for the neuromuscular blockade, inducing a better haemodynamic profile, exhibiting better sedation and improving the awakening condition.

Neurologic Assessment of the Neurocritical Care Patient.

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.

Results of surgical treatment for Sprengle's deformity with vertical corrective scapular osteotomy.

INTRODUCTION: Sprengle deformity is the most common congential anomaly of shoulder complex that is the result of scapular placement in cephalad abnormal position. The purpose of this study is the evaluation of clinical and radiological results of vertical corrective scapular osteotomy and comparision of these results with previous studies. METHODS: We retrospectively reviewed the results of the vertical corrective scapular osteotomy (VSO) with or without clavicular osteotomy and wake-up test in 31 consecutive patients at an average duration of follow up of 30 month (6 month-15 years). 22 patients were girls and 9 were boys. The average age of the patients was 7.3 years (3-13) at the time of surgery. We evaluated the clinical and radiological results of this method in last fallow-up. No funding was used for this study and there are no conflicts of interest. RESULTS: 31 surgical procedures were performed. All osteotomies were healed. No neurovascular complication. Postoperative the mean shoulder flexion and abduction were improved 30 and 36° respectively (p < 0.001). The mean improvement of superior scapular angle (S.S.A) and inferior scapular angle (I.S.A) were 16 and 21° respectively (p < 0.001). CONCLUSION: It is intuitive that more cosmetic scapular lowering with little chance of neurovascular problems can be achieved after VSO. In addition, scapular rotation can be corrected using this technique, which should be considered as one of the advantages of this technique.We believe that a properly applied VSO procedure in severe deformities is safe with predictable outcomes in the treatment of a complex deformity that provides favorable functional and cosmetic outcomes in the longer term.

Combined Use of Taylor Spatial Frame and Wake-up Test for Acute Correction of Idiopathic External Torsion of the Tibia: A Case Report.

INTRODUCTION: We herein report a case of idiopathic unilateral external torsion of the tibia treated with Taylor spatial frame (TSF) fixation combined with performance of the wake-up test under anesthesia. The wake-up test is performed toward the end of a surgical procedure after all corrections have been made and hardware has been placed. The patient is slowly awakened and asked to move their feet. After recovery from anesthesia, patients do not remember performing this test. CASE REPORT: A 17-year-old Japanese male patient complained of a gait disturbance because of external torsion of his foot. The patient was determined to have lateral tibial torsion with a pre-operative foot progression angle of 40.8°. Deformity correction using the TSF was considered to be safe. The tibia was derotated by -34.8°, and the patient had a post-operative foot progression angle of 7.0°. His symptoms and signs improved after derotation osteotomy at the low tibial portion. Two years postoperatively, the patient exhibited no leg length discrepancy or rotation malalignment of the lower extremities as measured both clinically and radiographically. CONCLUSION: To the best of our knowledge, there are no reports on the combined use of the TSF and wake-up test for acute correction of idiopathic external torsion of the tibia. Intraoperative use of the wake-up test with subsequent TSF fixation is effective and safe for acute correction of limb deformities.

A comparison of intravenous sugammadex and neostigmine + atropine reversal on time to consciousness during wake-up tests in spinal surgery.

OBJECTIVE: The effect of sugammadex on consciousness is not yet fully understood. This prospective, randomized, double-blind, multicenter study was performed to compare the effects of intravenous (IV) sugammadex and neostigmine + atropine reversals on time-to-consciousness during intraoperative wake-up tests in patients undergoing spinal surgery. SUBJECTS AND METHODS: A total of 66 American Society of Anesthesiologists I-II patients aged 10-25 years undergoing spinal surgery were recruited. In all patients, bispectral index (BIS), motor-evoked potential (MEP), somatosensory-evoked potentials (SSEP), and train-of-four (TOF) scores were monitored. Patients received the same total IV anesthesia protocol with a propofol-remifentanil mixture. Patients were randomly allocated into two groups. During wake-up test, when the TOF count reached 2 (T2), either sugammadex 2 mg.kg-1 in group S or neostigmine 0.04 mg.kg-1 + atropine 0.01 mg.kg-1 in group N were administered. BIS90, SSEP90, MEP90 was recorded when TOF ratio reached 90, whereas time-to-consciousness (Timecons) was recorded when the patient responded to verbal commands. RESULTS: BIS90 (77.4 ± 4.7, 74.8 ± 3.7), SSEP90(36 ± 9.9, 29.7 ± 8.5), and MEP90 (465.3 ± 34.8, 431.3 ± 28.2) values were significantly greater in group S than in group N (P < 0.05 for each variables). Timecons was significantly shorter with sugammadex than with the neostigmine + atropine combination (P < 0.05). CONCLUSION: Using IV sugammadex 2 mg.kg-1 reversal provides faster responses to verbal commands than neostigmine-atropine combination during the intraoperative wake-up test in patients undergoing spinal surgery because the time to consciousness was significantly shorter. This difference was thought to be related with faster return of neuromuscular transmission because the TOF ratio was >0.9 well before return of consciousness in both groups.

Comparison of intraoperative wake-up test performed under different methods of anesthesia in pa-tients undergoing scoliosis correction / 中华麻醉学杂志

Objective To compare the intraoperative wake-up test performed under different meth-ods of anesthesia in the patients undergoing scoliosis correction. Methods Sixty American Society of An-esthesiologists physical status Ⅰ or Ⅱ patients of both sexes, aged 14-35 yr, undergoing elective scoliosis correction, were divided into dexmedetomidine-based anesthesia group (D group) and sevoflurane-based anesthesia group (S group), with 30 cases in each group. Patients were tracheally intubated after induc-tion of anesthesia. Maintenance of anesthesia was as follows: remifentanil 0. 3 μg·kg-1 ·min-1 was intra-venously infused, dexmedetomidine 0. 2 μg·kg-1 ·h-1 was intravenously infused in group D, and group S inhaled low flow sevoflurane 1 L∕min with the end-tidal concentration of 0. 8％ - 1. 5％. Narcotrend index value was maintained at 30-45. The wake-up time, adverse events, requirement for vasoactive agents and blood loss during wake-up test were recorded. The wake-up quality was evaluated. Results All the pa-tients successfully completed wake-up tests. Compared with group S, the wake-up quality was significantly increased, the incidence of agitation and bucking was decreased during wake-up test, the blood loss was reduced during wake-up test (P<0. 05), and no significant change was found in wake-up time or require-ment for vasoactive agents in group D (P>0. 05). Conclusion Dexmedetomidine-based anesthesia pro-duces better efficacy for intraoperative wake-up test than sevoflurane-based anesthesia in the patients under-going scoliosis correction.

Impact of dexmedetomidine anesthesia on intraoperative wake-up test in Brucellar spondylitis undergoing surgery / 中华地方病学杂志

Objective To observe the effects of dexmedetomidine on intraoperative wake-up test in Brucellar spondylitis (BS) patients undergoing surgical operation.Methods Using the case control method,thirty-two patients undergoing BS surgical operation from January 2014 to December 2017 in Harbin the Fifth Hospital were enrolled in this study,the patients were randomly classified into the experimental group (n =16) and the control group (n =16).The two groups were anesthetized with midazolam,propofol,sufentanil and cisatracurium,then anesthesia was maintained with sevoffurane inhalation and a continuous intravenous infusion of remifentanil.In the experimental group,dexmedetomidine 0.4 μg· kg-1·h-1 was administered after tracheal intubation,while equal volume saline solution was given to control group.When the wake-up test was performed,the values of mean arterial pressure (MAP),heart rate (HR) and bispectral index (BIS) were recorded at the time points of preinduction (T0),just before wake-up (T1) and awakening (T2).The wake-up time,the amount of bleeding during the wake-up period,the wake-up quality rating and the sedation score were recorded.Results There was significant difference in HR and MAP at T0,T1 versus at T2 in control group [(98.8 ± 21.0) time/min vs (84.5 ± 8.1),(81.8 ± 1.7) time/min,(90.2 ± 7.5) mmHg vs (76.2 ± 5.7),(74.6 ± 8.5) mmHg,1 mmHg =0.133 kPa,P ＜ 0.05].In experimental group,HR and MAP were lower than those in control group at T2,and the difference between the two groups was statistically significant [(86.3 ± 12.3) time/min vs (98.8 ± 21.0) time/min,(77.9 ± 6.3) mmHg vs (90.2 ± 7.5) mmHg,t =-2.901,-4.995,P ＜ 0.05).The wake-up test quality was significantly better in test group than that in control group,the difference was statistically significant (excellent:13 cases vs 4 cases,good:2 cases vs 6 cases,poor:1 case vs 6 cases,x2 =4.571,P ＜ 0.05).The wake-up time and the amount of bleeding during wake-up period were less than that in control group,the difference was statistically significant [(14.5 ± 3.6) min vs (26.1 ± 4.5) min,(239.8 ± 53.9) ml vs (317.3 ± 54.8) ml,t =-7.980,-4.032,P ＜ 0.05].Conclusion Dexmedetomidine when continuous pumped at a rate of 0.4 μg· kg-1· h-1 could reduce the hemodynamic stress response during the wake-up test,improve the wakeup test quality,shorten the wake-up time and effectively improve the safety factor of operation during Brucellar surgical operation.

The Neurological Wake-up Test-A Role in Neurocritical Care Monitoring of Traumatic Brain Injury Patients?

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.

Early neurological wake-up test in intubated brain-injured patients: A long-term, single-centre experience.

BACKGROUND: In prehospital setting, a severe traumatic brain injury (TBI) requires tracheal intubation, sedation and mechanical ventilation pending the initial imagery. An early neurological wake-up test (ENWT), soon after the initial imaging assessment, allows a rapid neurological reassessment. This strategy authorises an initial clinical examination of reference with which will be compared the later examinations. The main objective of this study was to describe the characteristics of the patients who underwent an ENWT, and to determine its causes of failure. METHODS: We conducted a retrospective, observational, single-centre study including all intubated TBI admitted in the trauma centre. An ENWT was defined as cessation of sedation within 24h after TBI. Data concerning patient characteristics, CT-scan results, and outcomes were extracted from a prospective register of all intubated TBI admitted in the ICU. Characteristic of ENWT and causes of failure were retrieved from patient files. A multivariate logistic regression model was developed to determine the risk factors of ENWT failure. RESULTS: During 7 years, 242 patients with intubated TBI were included. An ENWT was started in 96 patients, for an overall rate at 40%. The ENWT was stopped in 38 patients (39.5%), mostly due to neurological deterioration in 27 cases (71%) or respiratory distress in 10 cases (26%). Significant predictors of ENWT failure were: the presence of subdural hematoma with a thickness >5mm on first imagery (OR=3.2; 95%CI [1.01-10.28]), and an initial GCS score <5 (OR=7.4; 95%CI [1.92-28.43]). Prevalence of poor outcome at 1year was lesser in patients with successful ENWT compared to those with failure or absence of ENWT: 4% vs. 48% and 49% (p<0.0001). CONCLUSIONS: The ENWT is achieved in 40% of patients, with a success rate of 60.5%. In presence of a subdural hematoma with a thickness >5mm or an initial GCS score <5, an ENWT failure may be expected.

Effect of dexmedetomidine on quality of intraoperative wake-up test in patients undergoing balloon occlusion test of the internal carotid artery / 中华麻醉学杂志

Objective To evaluate the effect of dexmedetomidine on the quality of intraoperative wake-up test in the patients undergoing balloon occlusion test of the internal carotid artery.Methods Forty-two patients of either sex with intracranial aneurysm,aged 57-78 yr,weighing 53-86 kg,of American Society of Anesthesiologists physical status Ⅱ or Ⅲ,scheduled for elective balloon occlusion test of the internal carotid artery under general anesthesia,were assigned into 2 groups (n =21 each) using a random number table:propofol conbined with remifentanil group (group PR) and dexmedetomidine combined with propofol and remifentanil group (group DPR).In group DPR,dexmedetomidine was intravenously infused over 15 min in a loading dose of 0.5 μg · kg-1 before induction of anesthesia,followed by an infusion of 0.3 μg · kg-1 · h-1 throughout surgery.Propofol and remifentanil were given by target-controlled infusion (TCI) after infusion of the loading dose.The patients were mechanically ventilated after placement of the laryngeal mask airway.Maintenance of anesthesia was as follows:propofol and remifentanil were given by TCI with the target plasma concentrations of 0.5-1.0 μg/ml and 1-3 ng/ml,respectively,in group DPR;propofol and remifentanil were given by TCI with the target plasma concentrations of 3-5 μg/ml and 3-6 ng/ml,respectively,in group PR.Bispectral index (BIS) value was maintained at 40-60.Before wakeup test,propofol infusion was stopped and the target plasma concentration of remifentanil was decreased to 0.5 ng/ml in two groups,and the infusion rate of dexmedetomidine was decreased to 0.1 pg · kg-1 · h-1 in group DPR.The wake-up time was recorded and the wake-up quality was assessed.After admission to the operating room (T0,baseline),at 10 min before wake-up test (T1),immediately after patients were wakened (T2),at 10 min after patients were wakened (T3) and at the end of wake-up test (T4),the mean blood pressure (MAP),heart rate,respiratory rate (RR),SpO2 and BIS values were recorded.The development of intraoperative awareness,emergence time,postoperative agitation,nausea and vomiting,regurgitation and aspiration and severe pain was recorded.Results MAP,heart rate,SpO2 and RR were all within the normal range during wake-up period in two groups.Compared with the baseline at To,MAP was significantly decreased at Ti,3,4 in group PR,and BIS value was decreased at T1-4 in DPR and PR groups (P＜0.05).Compared with group PR,MAP was significantly increased at T1.3,BIS value was decreased at T24,the wake-up time was shortened,Ramsay sedation score and wake-up quality were increased,the emergence time was shortened,and the incidence of agitation was deceased (P＜0.05),and no significant change was found in verbal rating scale scores assessed after extubation in group DPR (P ＞ 0.05).No cardiovascular events,respiratory depression,intraoperative awareness,postoperative nausea and voniting,regurgitation and aspiration or severe pain was found in two groups.Conclusion Dexmedetomidine can raise the quality of intraoperative wake-up test in the patients undergoing balloon occlusion test of the internal carotid artery.

Effects of different head positions during operation on wake-up time and quality among ankylosing spondylitis patients with thoracolumbar kyphosis following pedicle subtraction osteotomy / 现代临床护理

Objective To investigate the effects of different head positions during operation on wake-up time and quality among ankylosing spondylitis (AS) patients with thoracolumbar kyphosis following pedicle subtraction osteotomy (PSO).Methods Sixty patients were included in this study.All of them,treated with intravenous anesthesia,took the bow-prone position.The patients were randomly divided into two groups:the experiment group where the head was elevated by 10° and the control group where the head was not elevated.The two groups were compared in respect of wake-up time and quality of wake-up test.Results The wake-up time in the experiment group was significantly shorter as compared to that of the control group (1 3.7±2.0 min vs.24.2±2.7min,P＜0.05).The wake-up quality was better as well.Conclusion Elevation of the head by 10° can shorten wake-up time and improve the quality of wake-up test during the procedure of PSO for AS patients with thoracolumbar kyphosis.

Comparison of propofol and midazolam on patients undergoing spinal surgery with intraoperative wake-up test: randomized clinical trial / Comparação de propofol e midazolam em pacientes submetidos à cirurgia de coluna vertebral com teste de despertar no intraoperatório: estudo clínico randomizado

BACKGROUND AND OBJECTIVES: Instrumentation in correction operations for spinal deformities carries a 0.5-5% risk of injuring the spinal cord. The wake-up test is used for early detection of these injuries. In this study we compared the effects of propofol and midazolam during wake-up test in scoliosis surgery. METHODS: Thirty patients were randomly assigned as group P and group M. Anesthesia was induced with propofol 2.5 mg kg-1 for group P or midazolam 0.5 mg kg-1 for group M with remifentanil 0.5 µg kg-1 and cisatracurium 0.15 mg kg-1 for both groups. At the maintenance of anesthesia O2/air and infusions of remifentanil and cisatracurium were used. In group P, propofol 6-10 mg kg-1 h-1 and in group M, midazolam 0.5 mg mg kg-1 were preferred. Approximately 15 min before the wake-up test, all drugs were discontinued. At the wake-up test, anesthesiologist asked the patients to open their eyes and squeeze his/her hand at every 30 s until the patients responded. Then patients were told to wiggle their toes. Hemodynamic parameters, time of eye-opening, appropriate movement upon verbal command were evaluated. BIS frequency throughout the operation was recorded. RESULTS: The eye opening time was 9 ± 2.15 min in group P and 7 ± 3.15 min in group M. Motor movement time was 12 ± 2.55 min in group P and 21.25 ± 3.93 min in group M. CONCLUSION: Propofol provided better wake-up conditions and conducted a better neurologic assessment within the same BIS values than midazolam.

JUSTIFICATIVA E OBJETIVOS: A instrumentação em cirurgias de correção de deformidades da coluna vertebral tem risco de 0,5 a 5% de lesionar a medula espinhal. O teste de despertar é usado para a detecção precoce dessas lesões. Neste estudo comparamos os efeitos de propofol e midazolam durante o teste de despertar em cirurgia de escoliose. MÉTODOS: Trinta pacientes foram designados de forma aleatória para os grupos P e M. A anestesia foi induzida com propofol (2,5 mg kg-1) no grupo P ou midazolam (0,5 mg kg-1) no grupo M, com remifentanil (0,5 µg kg-1) e cisatracúrio (0,15 mg kg-1) em ambos os grupos. A manutenção da anestesia foi feita com O2/ar e infusões de remifentanil e cisatracúrio. Nos grupos P e M, respectivamente, doses de propofol (6-10 mg kg-1 h-1) e de midazolam (0,5 mg mg kg-1) foram preferidas. Aproximadamente 15 min antes do teste de despertar, todos os medicamentos foram interrompidos. No teste de despertar, o anestesiologista pedia ao paciente que abrisse os olhos e apertasse sua mão a cada 30 s até que o paciente respondesse. Depois, o paciente era solicitado a mexer os dedos dos pés. Os parâmetros hemodinâmicos, o tempo de abertura dos olhos e o movimento apropriado sob comando verbal foram avaliados. A frequência do BIS foi registrada durante toda a cirurgia. RESULTADOS: O tempo de abertura dos olhos foi de 9 ± 2,15 min no grupo P e de 7 ± 3,15 min no grupo M. O tempo de movimento motor foi de 12 ± 2,55 min no grupo P e de 21,25 ± 3,93 min no grupo M. CONCLUSÃO: Propofol proporcionou melhores condições de despertar e possibilitou uma melhor avaliação neurológica dentro dos mesmos valores do BIS que midazolam.

Comparison of propofol and midazolam on patients undergoing spinal surgery with intraoperative wake-up test: randomized clinical trial.

BACKGROUND AND OBJECTIVES: Instrumentation in correction operations for spinal deformities carries a 0.5-5% risk of injuring the spinal cord. The wake-up test is used for early detection of these injuries. In this study we compared the effects of propofol and midazolam during wake-up test in scoliosis surgery. METHODS: Thirty patients were randomly assigned as group P and group M. Anesthesia was induced with propofol 2.5 mg kg(-1) for group P or midazolam 0.5 mg kg(-1) for group M with remifentanil 0.5 µg kg(-1) and cisatracurium 0.15 mg kg(-1) for both groups. At the maintenance of anesthesia O2/air and infusions of remifentanil and cisatracurium were used. In group P, propofol 6-10 mg kg(-1)h(-1) and in group M, midazolam 0.5 mg mg kg(-1) were preferred. Approximately 15 min before the wake-up test, all drugs were discontinued. At the wake-up test, anesthesiologist asked the patients to open their eyes and squeeze his/her hand at every 30s until the patients responded. Then patients were told to wiggle their toes. Hemodynamic parameters, time of eye-opening, appropriate movement upon verbal command were evaluated. BIS frequency throughout the operation was recorded. RESULTS: The eye opening time was 9 ± 2.15 min in group P and 7 ± 3.15 min in group M. Motor movement time was 12 ± 2.55 min in group P and 21.25 ± 3.93 min in group M. CONCLUSION: Propofol provided better wake-up conditions and conducted a better neurologic assessment within the same BIS values than midazolam.

[Comparison of propofol and midazolam on patients undergoing spinal surgery with intraoperative wake-up test: randomized clinical trial]. / Comparação de propofol e midazolam em pacientes submetidos à cirurgia de coluna vertebral com teste de despertar no intraoperatório: estudo clínico randomizado.

BACKGROUND AND OBJECTIVES: Instrumentation in correction operations for spinal deformities carries a 0.5-5% risk of injuring the spinal cord. The wake-up test is used for early detection of these injuries. In this study we compared the effects of propofol and midazolam during wake-up test in scoliosis surgery. METHODS: Thirty patients were randomly assigned as group P and group M. Anesthesia was induced with propofol 2.5mgkg(-1) for group P or midazolam 0.5mgkg(-1) for group M with remifentanil 0.5µgkg(-1) and cisatracurium 0.15mgkg(-1) for both groups. At the maintenance of anesthesia O2/air and infusions of remifentanil and cisatracurium were used. In group P, propofol 6-10mgkg(-1)h(-1) and in group M, midazolam 0.5mgmgkg(-1) were preferred. Approximately 15min before the wake-up test, all drugs were discontinued. At the wake-up test, anesthesiologist asked the patients to open their eyes and squeeze his/her hand at every 30s until the patients responded. Then patients were told to wiggle their toes. Hemodynamic parameters, time of eye-opening, appropriate movement upon verbal command were evaluated. BIS frequency throughout the operation was recorded. RESULTS: The eye opening time was 9±2.15min in group P and 7±3.15min in group M. Motor movement time was 12±2.55min in group P and 21.25±3.93min in group M. CONCLUSION: Propofol provided better wake-up conditions and conducted a better neurologic assessment within the same BIS values than midazolam.

Median effective effect-site concentration of sufentanil for wake-up test in adolescents undergoing surgery: a randomized trial.

BACKGROUND: To determine the median effective concentration of sufentanil as an analgesic during wake-up tests after sevoflurane anesthesia during surgery for adolescent idiopathic scoliosis (AIS). METHODS: This is a randomised controlled trial. Sixty patients aged 13-18 years scheduled for AIS surgery were randomized into six groups of 10 patients each to receive target effect-site concentrations of sufentanil of 0.19, 0.1809, 0.1723, 0.1641, 0.1563, and 0.1489 ng/ml (target concentration ratio, 1.05). Wake-up time was recorded. Median EC50 and 95% confidence interval (CI) for sufentanil target-controlled infusion (TCI) were determined using Kärber's method. The primary outcome was median EC50 for sufentanil TCI as an analgesic during the wake-up test after sevoflurane anesthesia during surgery for AIS. RESULTS: The EC50 and 95% CI of sufentanil TCI were 0.1682 ng/ml and 0.1641 ~ 0.1724 ng/ml, respectively. CONCLUSIONS: The EC50 of sufentanil TCI was 0.1682 ng/ml (95% CI: 0.1641 ~ 0.1724 ng/ml) during sevoflurane anesthesia in adolescents undergoing surgery for idiopathic scoliosis with intraoperative wake-up tests. TRIAL REGISTRATION: Clinicaltrials.gov identifier: ChiCTR-TTRCC-12002696.

Quality of intraoperative wake-up test in patients undergoing scoliosis correction surgery under etomidate-based anesthesia / 中华麻醉学杂志

Objective To evaluate the quality of intraoperative wake?up test in the patients undergoing scoliosis correction surgery under etomidate?based anesthesia. Methods Thirty patients of both sexes, aged 13-32 yr, weighing 40-65 kg, of ASA physical statusⅠorⅡ, undergoing elective scoliosis correction surgery, were randomly assigned into etomidate group ( group E, n=15 ) or propofol group (group P, n=15) using a random number table. Anesthesia was induced with etomid 0.3 mg∕kg (group E) or propofol 2mg∕kg ( group P ) injected intravenously, midazolam, fentanyl and rocuronium. The patients were mechanically ventilated after naso?tracheal intubation. Etomidate 0.6-1. 2 mg · kg-1 · h-1 and propofol 8- 10 mg·kg-1 ·h-1 were infused intravenously during surgery in E and P groups, respectively. Both remifentanil and cisatracurium were used for maintenance of anesthesia in the two groups. Cisatracurium infusion was stopped before wake?up test. The infusion rate of propofol was adjusted to 4 mg·kg-1 ·h-1 at 15 min before wake?up test. After the scoliotic angle was corrected, infusion of etomidate and propofol was stopped, and the infusion rate of remifentanil was adjusted to 0.025μg·kg-1 ·min-1 in both groups. The wake?up time was recorded, and the quality of wake?up was assessed. Mean arterial pressure (MAP) and heart rate were recorded before anesthesia ( T0 ) , immediately before the patients were awakened ( T1 ) , when the patients responded to commands from doctors ( T2 ) , and after anesthesia was deepened ( T3 ) . At T0 , the end of surgery ( T4 ) , and 24 h after surgery ( T5 ) , blood samples were collected from the internal jugular vein for determination of plasma cortisol concentrations. Results The patients were awakened successfully in the two groups, and there were no significant differences in the wake?up time, quality of wake?up, and MAP, HR and plasma cortisol concentrations at each time point between the two groups. MAP and HR were significantly higher at T2 than at T0 in the two groups. MAP and HR were within the normal range during wake?up test, and no patients developed severer cardiovascular events in the two groups. Conclusion Etomidate?based anesthesia provides better quality of intraoperative wake?up test in the patients undergoing scoliosis correction surgery, which is similar to that of propofol?based anesthesia.

Effect of dexmedetomidine on quality of wake-up test in patients undergoing posterior osteotomy correction surgery / 中华麻醉学杂志

Objective To evaluate the effect of dexmedetomidine on quality of wake-up test in the patients undergoing posterior osteotomy correction surgery.Methods Ninety-seven patients of both sexes,aged 17-59 yr,of ASA physical status Ⅰ or Ⅱ,with body mass index 18.5-25.0 kg/m2 and global kyphosis angle＞60°,scheduled for elective posterior osteotomy correction surgery under general anesthesia,were randomly divided into 2 groups using a random number table:control group C (n=46) and group D (n =51).In group D,dexmedetomidine 1.0 μg/kg was infused over 15 min before induction of anesthesia,and group C received the equal volume of normal saline instead.Anesthesia was induced with iv midazolam,propofol,fentanyl,vecuronium and dexamethasone in C and D groups.Mechanical ventilation was performed after tracheal intubation.Anesthesia was maintained with infusion of cisstracurium,propofol and remifentanil.Dexmedetomidine 0.3 μg · kg-1 · h-1 was infused throughout the surgery in group D,and meanwhile normal saline was given throughout the surgery in group C.The anesthetic drugs for maintenance except dexmedetomidine were discontinued at the beginning of the wake-up test.The wake-up time was recorded and the wake-up quality was assessed.Ramsay sedation scores and Riker sedation-agitation scale scores were also recorded when all the patients were successfully awakened.The development of cardiovascular events during wake-up test and intraoperative awareness was recorded.Results The wake-up quality was significantly higher,Riker sedation-agitation scale scores were lower,Ramsay sedation scores were higher,the incidence of nausea and vomiting was lower,and no significant change was found in wake-up time in group D.No intraoperative awareness was observed in the two groups.Conclusion Dexmedetomidine can raise wake-up quality without prolonging wake-up time and with stable hemodynamics and fewer side effects in the patients undergoing posterior osteotomy correction surgery.

Comparative study of propofol combined with sufentanil or remifentanil in wake-up test during scoliosis surgery / 临床麻醉学杂志

Objective To compare the influence of propofol combined with sufentanil or remifentanil on the quality of wake-up during scoliosis surgery by wake-up test.Methods Fifty pa-tients undergoing scoliosis surgery were randomized into two groups.During the surgery,propofol combined with sufentanily 0.3-0.6 μg·kg-1·h-1 (group SF)or remifentanil 0.2-0.3 μg·kg-1·min-1 (group RF)were continuously infused to maintain anesthesia,and BIS was maintained at 40-60.In wake-up test,the infusion of sufentanyl in group SF was paused and,the infusion rate of remifentanil in group RF was adjusted to 0.05 μg·kg-1·min-1 until the patient completed the wake-up test under instruction.The time that spontaneous breathing occurred,body movement was detected and the capa-bility to follow instructions in both two groups were recorded.MAP,HR,PET CO2 were measured at the time 10 min after medication adjustment (T1 ),waking up(T2 )and 10 min after waking up (T3 ), respectively,in both two groups.Wake-up quality was also recorded.Results The time that sponta-neous breathing occurred,body movement was detected and the capability to follow instructions in group RF were significantly shorter than those in group SF (P <0.05).At T2 the incidence of agita-tion in group RF was significantly higher than that in group SF(P <0.05).And the hemodynamics of group SF were more stable than those of group RF (P <0.05).Conclusion Propofol combined with sufentanil can improve wake-up quality during scoliosis surgery,but the wake-up time is relatively lon-ger.