Download PDF
J Pediatr Intensive Care 2020; 09(01): 064-069
DOI: 10.1055/s-0039-1698758
Case Report
Georg Thieme Verlag KG Stuttgart · New York

Management of Paroxysmal Sympathetic Hyperactivity with Dexmedetomidine and Propranolol Following Traumatic Brain Injury in a Pediatric Patient

Joshua W. Branstetter 
1   Department of Pharmacy, UF Health Jacksonville, Jacksonville, Florida, United States
2   University of Florida College of Pharmacy, Jacksonville, Florida, United States
,
Kelsey L. Ohman
1   Department of Pharmacy, UF Health Jacksonville, Jacksonville, Florida, United States
2   University of Florida College of Pharmacy, Jacksonville, Florida, United States
,
Donald W. Johnson
1   Department of Pharmacy, UF Health Jacksonville, Jacksonville, Florida, United States
2   University of Florida College of Pharmacy, Jacksonville, Florida, United States
,
Brian W. Gilbert
3   Department of Pharmacy, Wesley Medical Center, Wichita, Kansas, United States
› Author Affiliations
Further Information

Publication History

17 April 2019

02 September 2019

Publication Date:
18 October 2019 (online)

    Permissions and Reprints

Abstract

We report a case of pharmacologic management of pediatric paroxysmal sympathetic hyperactivity (PSH) in a patient who experienced symptomatic resolution with dexmedetomidine and propranolol. Following a blunt traumatic subdural hematoma and diffuse axonal injury, an 8-year-old male developed PSH on approximately day 5 of the hospitalization. PSH symptoms identified in this patient were hyperthermia, tachycardia, posturing, and hypertension with associated elevations in intracranial pressure. Episodes of PSH continued to be observed despite appropriate titration of opiates, sedatives, and traditional blood pressure management. Dexmedetomidine and propranolol were subsequently initiated to attenuate acute episodes of PSH. A reduction in sedative requirements and improvement in symptoms followed, which facilitated successful extubation. The combination of propranolol and dexmedetomidine was followed by a decrease in the frequency and severity of acute episodes of PSH. After utilization of multiple treatment modalities to control PSH episodes in our patient, propranolol and dexmedetomidine may have helped attenuate PSH signs and symptoms.

Keywords

traumatic brain injury - paroxysmal sympathetic hyperactivity - pediatrics - dexmedetomidine - propranolol
 

  • References

  • 1 Meyer KS. Understanding paroxysmal sympathetic hyperactivity after traumatic brain injury. Surg Neurol Int 2014; 5 (Suppl. 13) S490-S492
    CrossrefPubMedGoogle Scholar
  • 2 Kirk KA, Shoykhet M, Jeong JH. , et al. Dysautonomia after pediatric brain injury. Dev Med Child Neurol 2012; 54 (08) 759-764
    CrossrefPubMedGoogle Scholar
  • 3 Baguley IJ, Cameron ID, Green AM, Slewa-Younan S, Marosszeky JE, Gurka JA. Pharmacological management of dysautonomia following traumatic brain injury. Brain Inj 2004; 18 (05) 409-417
    CrossrefPubMedGoogle Scholar
  • 4 Bullard DE. Diencephalic seizures: responsiveness to bromocriptine and morphine. Ann Neurol 1987; 21 (06) 609-611
    CrossrefPubMedGoogle Scholar
  • 5 Payen D, Quintin L, Plaisance P, Chiron B, Lhoste F. Head injury: clonidine decreases plasma catecholamines. Crit Care Med 1990; 18 (04) 392-395
    CrossrefPubMedGoogle Scholar
  • 6 Siefferman JW, Lai G. Propranolol for paroxysmal sympathetic hyperactivity with lateralizing hyperhidrosis after stroke. Case Rep Neurol Med 2015; 2015: 421563
    PubMedGoogle Scholar
  • 7 Russo RN, O'Flaherty S. Bromocriptine for the management of autonomic dysfunction after severe traumatic brain injury. J Paediatr Child Health 2000; 36 (03) 283-285
    CrossrefPubMedGoogle Scholar
  • 8 Pozzi M, Conti V, Locatelli F. , et al. Paroxysmal sympathetic hyperactivity in pediatric rehabilitation: clinical factors and acute pharmacological management. J Head Trauma Rehabil 2015; 30 (05) 357-363
    CrossrefPubMedGoogle Scholar
  • 9 Feng Y, Zheng X, Fang Z. Treatment progress of paroxysmal sympathetic hyperactivity after acquired brain injury. Pediatr Neurosurg 2015; 50 (06) 301-309
    CrossrefPubMedGoogle Scholar
  • 10 Raithel DS, Ohler KH, Porto I, Bicknese AR, Kraus DM. Morphine: an effective abortive therapy for pediatric paroxysmal sympathetic hyperactivity after hypoxic brain injury. J Pediatr Pharmacol Ther 2015; 20 (04) 335-340
    PubMedGoogle Scholar
  • 11 Baguley IJ, Perkes IE, Fernandez-Ortega JF, Rabinstein AA, Dolce G, Hendricks HT. ; Consensus Working Group. Paroxysmal sympathetic hyperactivity after acquired brain injury: consensus on conceptual definition, nomenclature, and diagnostic criteria. J Neurotrauma 2014; 31 (17) 1515-1520
    CrossrefPubMedGoogle Scholar
  • 12 Krach LE, Kriel RL, Morris WF. , et al. Central autonomic dysfunction following acquired brain injury in children. Neurorehabil Neural Repair 1997; 11 (01) 41-45
    CrossrefPubMedGoogle Scholar
  • 13 Perkes I, Baguley IJ, Nott MT, Menon DK. A review of paroxysmal sympathetic hyperactivity after acquired brain injury. Ann Neurol 2010; 68 (02) 126-135
    CrossrefPubMedGoogle Scholar
  • 14 Baguley IJ, Nott MT, Slewa-Younan S, Heriseanu RE, Perkes IE. Diagnosing dysautonomia after acute traumatic brain injury: evidence for overresponsiveness to afferent stimuli. Arch Phys Med Rehabil 2009; 90 (04) 580-586
    CrossrefPubMedGoogle Scholar
  • 15 Baguley IJ. The excitatory: inhibitory ratio model (EIR model): an integrative explanation of acute autonomic overactivity syndromes. Med Hypotheses 2008; 70 (01) 26-35
    CrossrefPubMedGoogle Scholar
  • 16 Haddad SH, Arabi YM. Critical care management of severe traumatic brain injury in adults. Scand J Trauma Resusc Emerg Med 2012; 20: 12
    CrossrefPubMedGoogle Scholar
  • 17 Carney N, Totten AM, O'Reilly C. , et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery 2017; 80 (01) 6-15
    CrossrefPubMedGoogle Scholar
  • 18 Fernandez-Ortega JF, Prieto-Palomino MA, Garcia-Caballero M, Galeas-Lopez JL, Quesada-Garcia G, Baguley IJ. Paroxysmal sympathetic hyperactivity after traumatic brain injury: clinical and prognostic implications. J Neurotrauma 2012; 29 (07) 1364-1370
    CrossrefPubMedGoogle Scholar
  • 19 Alofisan TO, Algarni YA, Alharfi IM. , et al. Paroxysmal sympathetic hyperactivity after severe traumatic brain injury in children: prevalence, risk factors, and outcome. Pediatr Crit Care Med 2019; 20 (03) 252-258
    CrossrefPubMedGoogle Scholar
  • 20 Hogue Jr CW, Talke P, Stein PK, Richardson C, Domitrovich PP, Sessler DI. Autonomic nervous system responses during sedative infusions of dexmedetomidine. Anesthesiology 2002; 97 (03) 592-598
    CrossrefPubMedGoogle Scholar
  • 21 Goddeau Jr RP, Silverman SB, Sims JR. Dexmedetomidine for the treatment of paroxysmal autonomic instability with dystonia. Neurocrit Care 2007; 7 (03) 217-220
    CrossrefPubMedGoogle Scholar
  • 22 Dillon RC, Palma JA, Spalink CL. , et al. Dexmedetomidine for refractory adrenergic crisis in familial dysautonomia. Clin Auton Res 2017; 27 (01) 7-15
    CrossrefPubMedGoogle Scholar
  • 23 Constantin J-M, Momon A, Mantz J. , et al. Efficacy and safety of sedation with dexmedetomidine in critical care patients: a meta-analysis of randomized controlled trials. Anaesth Crit Care Pain Med 2016; 35 (01) 7-15
    PubMedGoogle Scholar
  • 24 Karlsson BR, Forsman M, Roald OK, Heier MS, Steen PA. Effect of dexmedetomidine, a selective and potent alpha 2-agonist, on cerebral blood flow and oxygen consumption during halothane anesthesia in dogs. Anesth Analg 1990; 71 (02) 125-129
    PubMedGoogle Scholar
  • 25 Drummond JC, Dao AV, Roth DM. , et al. Effect of dexmedetomidine on cerebral blood flow velocity, cerebral metabolic rate, and carbon dioxide response in normal humans. Anesthesiology 2008; 108 (02) 225-232
    CrossrefPubMedGoogle Scholar
  • 26 Peng Y, Zhu H, Chen H. , et al. Dexmedetomidine attenuates acute paroxysmal sympathetic hyperactivity. Oncotarget 2017; 8 (40) 69012-69019
    CrossrefPubMedGoogle Scholar