Knowledge

Induced coma

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Considering the high risks of medically induced comas, protocols such as the ABCDEF Bundle and PADIS guidelines have been developed to guide ICU teams to avoid unnecessary sedation and comas. ICU teams that master these protocols to keep patients as awake and mobile as possible are called "Awake and
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The presence of an endotracheal tube and mechanical ventilation alone are not indications of continuous sedation and coma. Only certain conditions such as intracranial hypertension, refractory status epilepticus, the inability to oxygenate with movement, et cetera justify the high risks of medically
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About 60% of the glucose and oxygen used by the brain is meant for its electrical activity and the rest for all other activities such as metabolism. When barbiturates are given to brain injured patients for induced coma, they act by reducing the electrical activity of the brain, which reduces the
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Although patients are not sleeping while sedated, they can experience hallucinations and delusions that are often graphic and traumatizing in nature. This can lead to post-ICU PTSD after hospital discharge. Patients that develop ICU delirium are at 120 times greater risk of long-term cognitive
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Pun, Brenda T.; Balas, Michele C.; Barnes-Daly, Mary Ann; Thompson, Jennifer L.; Aldrich, J. Matthew; Barr, Juliana; Byrum, Diane; Carson, Shannon S.; Devlin, John W.; Engel, Heidi J.; Esbrook, Cheryl L.; Hargett, Ken D.; Harmon, Lori; Hielsberg, Christina; Jackson, James C. (January 2019).
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Shehabi, Yahya; Bellomo, Rinaldo; Reade, Michael C.; Bailey, Michael; Bass, Frances; Howe, Belinda; McArthur, Colin; Seppelt, Ian M.; Webb, Steve; Weisbrodt, Leonie; Sedation Practice in Intensive Care Evaluation (SPICE) Study Investigators; ANZICS Clinical Trials Group (2012-10-15).
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until burst suppression or cortical electrical silence (isoelectric "flatline") is attained. Once there is improvement in the patient's general condition, the barbiturates are withdrawn gradually and the patient regains consciousness.
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Girard, Timothy D.; Jackson, James C.; Pandharipande, Pratik P.; Pun, Brenda T.; Thompson, Jennifer L.; Shintani, Ayumi K.; Gordon, Sharon M.; Canonico, Angelo E.; Dittus, Robert S.; Bernard, Gordon R.; Ely, E. Wesley (July 2010).
233:. Some studies have found that barbiturate-induced coma can reduce intracranial hypertension but does not necessarily prevent brain damage. Furthermore, the reduction in intracranial hypertension may not be sustained. Some 218:
metabolic and oxygen demand. Their action limits oxidative damage to lipid membranes and may scavenge free radicals. They also lead to reduced vasogenic edema, fatty acid release and intracellular calcium release.
257:. If the patient survives, cognitive impairment may also follow recovery from the coma. Due to these risks, barbiturate-induced coma should be reserved for cases of refractory intracranial pressure elevation. 848:"The Brain Trauma Foundation. The American Association of Neurological Surgeons. The Joint Section on Neurotrauma and Critical Care. Use of barbiturates in the control of intracranial hypertension". 969: 883:
Lee MW, Deppe SA, Sipperly ME, Barrette RR, Thompson DR (June 1994). "The efficacy of barbiturate coma in the management of uncontrolled intracranial hypertension following neurosurgical trauma".
175:. This is associated with a doubled risk of mortality during hospital admission. For every one day of delirium, there is a 10% increased risk of death. Medically induced comas that achieve a 1096:
Schalén W, Sonesson B, Messeter K, Nordström G, Nordström CH (1992). "Clinical outcome and cognitive impairment in patients with severe head injuries treated with barbiturate coma".
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Survivors of prolonged medically induced comas are at high risk of suffering from post-ICU syndrome and may require extended physical, cognitive, and psychological rehabilitation.
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Ely, E. Wesley; Shintani, Ayumi; Truman, Brenda; Speroff, Theodore; Gordon, Sharon M.; Harrell, Frank E.; Inouye, Sharon K.; Bernard, Gordon R.; Dittus, Robert S. (2004-04-14).
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Walking ICUs". These are teams that only implement medically induced comas when the possible benefits of sedation outweigh the high risks during specific cases. 
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may be averted. Several studies have supported this theory by showing reduced mortality when treating refractory intracranial hypertension with a barbiturate coma.
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Salluh, Jorge I. F.; Wang, Han; Schneider, Eric B.; Nagaraja, Neeraja; Yenokyan, Gayane; Damluji, Abdulla; Serafim, Rodrigo B.; Stevens, Robert D. (2015-06-03).
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Induced coma usually results in significant systemic adverse effects. The patient is likely to completely lose respiratory drive and require
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Nordby HK, Nesbakken R (1984). "The effect of high dose barbiturate decompression after severe head injury. A controlled clinical trial".
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have failed to demonstrate any survival or morbidity benefit of induced coma in diverse conditions such as neurosurgical operations,
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The primary mechanism of protection involves a reduction in CMRo2 of up to 55% to 60% at which point the EEG becomes isoelectric.
737:"Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults" 1162: 312: 1057:"The University of Toronto head injury treatment study: a prospective, randomized comparison of pentobarbital and mannitol" 1370: 1355: 1295: 985:
approximately 60% of CMRO2 is utilized for neuronal function (with the remainder being required for cellular integrity)
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Therapeutic EEG response: burst suppression or cortical electrical silence (with preservation of SSEP and BAEF).
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Pan, Yanbin; Yan, Jianlong; Jiang, Zhixia; Luo, Jianying; Zhang, Jingjing; Yang, Kaihan (2019-07-10).
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Brain disruption from sedation can lead to an eight times increased risk of the development of
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The Canadian Journal of Neurological Sciences. Le Journal Canadien des Sciences Neurologiques
266: 207: 679:"Delirium as a predictor of long-term cognitive impairment in survivors of critical illness" 1604: 1424: 344: 1030: 392:"'Multimodal, patient-centred symptom control': a strategy to replace sedation in the ICU" 8: 1647: 1554: 1475: 1365: 1360: 1350: 1303: 1220: 1204: 1001: 199: 348: 1696: 1527: 1460: 1377: 1338: 1313: 1238: 1121: 943: 769: 736: 711: 678: 525: 468: 435: 367: 332: 254: 210:. The hope is that, with the swelling relieved, the pressure decreases and some or all 123: 412: 1799: 1545: 1345: 1323: 1308: 1199: 1113: 1078: 935: 900: 865: 825: 774: 756: 716: 698: 652: 625: 617: 577: 569: 530: 512: 493:"Outcome of delirium in critically ill patients: systematic review and meta-analysis" 473: 455: 416: 372: 308: 242: 35: 1125: 947: 127: 1657: 1328: 1105: 1068: 927: 892: 857: 764: 748: 706: 690: 609: 561: 520: 504: 463: 447: 408: 362: 352: 1683: 1581: 1455: 752: 694: 357: 84: 1055:
Schwartz ML, Tator CH, Rowed DW, Reid SR, Meguro K, Andrews DF (November 1984).
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An J, Jonnalagadda D, Moura V, Purdon PL, Brown EN, Westover MB (2018).
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The infusion dose rate of barbiturates is increased under monitoring by
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Barbiturates reduce the metabolic rate of brain tissue, as well as the
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often results. The completely immobile patient is at increased risk of
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Controversy exists over the benefits of using barbiturates to control
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Eikermann, Matthias; Needham, Dale M; Devlin, John W (May 12, 2023).
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in the brain narrow, resulting in a shrunken brain, and hence lower
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level of −4 or −5 are an independent predictor of death.  
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European Society of Paediatric and Neonatal Intensive Care
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American Journal of Respiratory and Critical Care Medicine
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Critical illness–related corticosteroid insufficiency
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Mariano GL, Fink ME, Hoffman C, Rosengart A (2014).
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that have not responded to other treatments, and in
301:"Intracranial pressure: monitoring and management." 122:, as a last line of treatment in certain cases of 152:and often requires the use of vasopressor drugs. 1844: 917: 824:, Treasure Island, FL: StatPearls Publishing, 651:. Treasure Island, FL: StatPearls Publishing. 433: 1163: 1000:. CNS Clinic – Jordan – Amman. Archived from 856:(6–7). Mary Ann Liebert, Inc.: 527–530 2000. 294: 292: 290: 288: 286: 103:. Other intravenous anesthetic drugs such as 1177: 815: 642: 303:. In Hall JB, Schmidt GA, Kress JP (eds.). 114:Drug-induced comas are used to protect the 1170: 1156: 283: 1072: 768: 710: 524: 467: 440:International Journal of Nursing Sciences 366: 356: 797:Society of Critical Care Medicine (SCCM) 326: 324: 87:) brought on by a controlled dose of an 998:"Cerebral protection and resuscitation" 643:Ali, Mohammed; Cascella, Marco (2023). 1845: 960: 1151: 321: 1658:Recombinant activated protein C 1371:Multiple organ dysfunction syndrome 1356:Acute respiratory distress syndrome 1296:Multiple organ dysfunction syndrome 816:Smith, Sarah; Rahman, Omar (2023), 148:can complicate efforts to maintain 13: 63: – also known as a 14: 1874: 1769:Society of Critical Care Medicine 1466:Ventilator-associated lung injury 1135: 79: – is a temporary 1471:Ventilator-associated pneumonia 1404:Critical illness polyneuropathy 1089: 1048: 1019: 990: 954: 911: 876: 841: 809: 785: 727: 818:"Post-Intensive Care Syndrome" 669: 636: 588: 541: 484: 427: 383: 1: 1250:Geriatric intensive-care unit 1233:Pediatric intensive care unit 413:10.1016/S2213-2600(23)00141-8 307:(4th ed.). McGraw Hill. 277: 202:. With these reductions, the 1653:Neuromuscular-blocking drugs 1596:Nutritional supplementation 1227:Neonatal intensive care unit 1029:. Trauma.org. Archived from 753:10.1097/CCM.0000000000003482 695:10.1097/CCM.0b013e3181e47be1 358:10.1371/journal.pone.0205789 7: 1753:Water-electrolyte imbalance 1587:Early goal-directed therapy 452:10.1016/j.ijnss.2019.05.008 305:Principles of Critical Care 260: 150:cerebral perfusion pressure 144:; gut motility is reduced; 10: 1879: 1605:Total parenteral nutrition 1538:Life-supporting treatments 1245:Critical illness insurance 614:10.1164/rccm.201203-0522OC 160:as well as infection from 1787: 1774:Surviving Sepsis Campaign 1761: 1725: 1682: 1620: 1570:Ventricular assist device 1565:Intra-aortic balloon pump 1536: 1516:Pulmonary artery catheter 1488: 1438: 1396: 1265: 1258: 1213: 1185: 1074:10.1017/s0317167100045960 793:"SCCM | PADIS Guidelines" 231:intracranial hypertension 193: 131:intracranial hypertension 46: 34: 26: 21: 566:10.1001/jama.291.14.1753 73:barbiturate-induced coma 1858:Intensive care medicine 1668:Stress ulcer prevention 1612:Therapeutic hypothermia 1511:Central venous catheter 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200:cerebral blood flow 1697:Glasgow Coma Scale 1648:Intravenous fluids 1528:Screening cultures 1496:Arterial blood gas 1461:Refeeding syndrome 1378:Neonatal infection 1339:Vasodilatory shock 1314:Distributive shock 1239:Coronary care unit 1110:10.1007/BF01400613 1027:"Barbiturate Coma" 1004:on 4 November 2020 932:10.1007/BF01406868 255:status epilepticus 124:status epilepticus 1840: 1839: 1800:Internal medicine 1546:Airway management 1484: 1483: 1324:Obstructive shock 1309:Cardiogenic shock 1033:on 19 August 2016 560:(14): 1753–1762. 509:10.1136/bmj.h2538 314:978-0-07-173881-1 235:randomized trials 83:(a deep state of 77:drug-induced coma 57: 56: 16:Medical procedure 1870: 1561:Cardiac devices 1415:Decubitus ulcers 1329:Neurogenic shock 1263: 1262: 1172: 1165: 1158: 1149: 1148: 1130: 1129: 1104:(3–4): 153–159. 1093: 1087: 1086: 1076: 1052: 1046: 1045: 1040: 1038: 1023: 1017: 1016: 1011: 1009: 994: 988: 987: 982: 980: 975:on 23 April 2016 974: 967: 958: 952: 951: 926:(3–4): 157–166. 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Index

Specialty
Neurology
edit on Wikidata
coma
unconsciousness
anesthetic
barbiturate
pentobarbital
thiopental
midazolam
propofol
brain
neurosurgery
status epilepticus
refractory
intracranial hypertension
traumatic brain injury
mechanical ventilation
hypotension
cerebral perfusion pressure
Hypokalemia
bed sores
catheters
ICU delirium
RASS
cerebral blood flow
blood vessels
intracranial pressure
brain damage
electroencephalography

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