Paroxysmal Sympathetic Hyperactivity After Severe Traumatic Brain Injury in Children: Prevalence, Risk Factors, and Outcome

The Australian Traumatic Brain Injury Initiative: Systematic Review and Consensus Process to Determine the Predictive Value of Demographic, Injury Event, and Social Characteristics on Outcomes for People With Moderate-Severe Traumatic Brain Injury

The objective of the Australian Traumatic Brain Injury (AUS-TBI) Initiative is to develop a data dictionary to inform data collection and facilitate prediction of outcomes of people who experience moderate-severe TBI in Australia. The aim of this systematic review was to summarize the evidence of the association between demographic, injury event, and social characteristics with outcomes, in people with moderate-severe TBI, to identify potentially predictive indicators. Standardized searches were implemented across bibliographic databases to March 31, 2022. English-language reports, excluding case series, which evaluated the association between demographic, injury event, and social characteristics, and any clinical outcome in at least 10 patients with moderate-severe TBI were included. Abstracts and full text records were independently screened by at least two reviewers in Covidence. A pre-defined algorithm was used to assign a judgement of predictive value to each observed association. The review findings were discussed with an expert panel to determine the feasibility of incorporation of routine measurement into standard care. The search strategy retrieved 16,685 records; 867 full-length records were screened, and 111 studies included. Twenty-two predictors of 32 different outcomes were identified; 7 were classified as high-level (age, sex, ethnicity, employment, insurance, education, and living situation at the time of injury). After discussion with an expert consensus group, 15 were recommended for inclusion in the data dictionary. This review identified numerous predictors capable of enabling early identification of those at risk for poor outcomes and improved personalization of care through inclusion in routine data collection.

Symptom Management in Children Who Are Neurologically Impaired for the Primary Care Medical Home

Children with neurologic impairment are a growing population of pediatric patients who require care from a large team of physicians to maintain their health. These children often have similar clinical patterns and symptoms that occur because of their neurologic impairment. Families often seek care first from their primary care home to identify and guide initial steps in management. Identifying the symptoms outlined in the 4 cases in this article will help alleviate consequences of delayed care for these patients and provide opportunities for shared decision-making with the family's goals of care for their child. [Pediatr Ann. 2024;53(3):e82-e87.].

Paroxysmal Sympathetic Hyperactivity after Traumatic Brain Injury: Current Understanding and Therapeutic Options

How to cite this article: Nasa P, Majeed NA, Juneja D. Paroxysmal Sympathetic Hyperactivity after Traumatic Brain Injury: Current Understanding and Therapeutic Options. Indian J Crit Care Med 2024;28(2):97-99.

How to predict the outcome of primary brainstem hemorrhage: Six-year results of a single-center retrospective analysis

Primary brainstem hemorrhage (PBH) is one of the most fatal intracranial hemorrhages, evaluating the prognosis in the early stage is vital for appropriate therapeutic planning. Our study aimed to identify risk factors for 30-day mortality and 90-day functional recovery of PBH. Data from 63 patients with PBH admitted to Beijing Chaoyang Hospital between 2016 and 2022 were retrieved for this study. We grouped the patients according to 30-day survival or 90-day functional recovery. Independent risk factors of 30-day mortality and 90-day functional recovery were identified by univariate and multivariate logistic regression analyses. 31 patients (49.2%) died within 30 days and 22 patients (34.9%) achieved better functional recovery. By multivariate analysis, Glasgow coma scale <9 on admission and tachycardia were significantly associated with 30-day mortality, while the hematoma volume >5 mL was an independent risk factor for 90-day functional recovery. Initial level of consciousness, tachycardia, massive hematoma were risk factors for prognosis, which must be seriously evaluated for therapeutic planning.

Rehabilitation Care of the Child with an Acute Severe Traumatic Brain Injury

Children with traumatic brain injury (TBI) represent a unique and evolving population. Recovery and long-term prognosis are variable given the heterogeneity of ages, developmental stages, and types of injuries. This article summarizes important information regarding severe TBI epidemiology, pathophysiology, classification, and acute management. Early and longitudinal involvement of rehabilitation experts, such as pediatric physiatrists, is critical in managing complications and optimizing outcomes.

Procalcitonin and Pediatric Traumatic Brain Injury: Differentiating Neuro-Storming From Infection

INTRODUCTION

Recurrent febrile episodes represent a diagnostic challenge in the pediatric traumatic brain injury (TBI) population as they may indicate presence of infection versus sterile neuro-storming. Procalcitonin (PCT) is a promising biomarker used in pediatric sepsis; however, data are limited regarding use in TBI. We hypothesized PCT helps discern neuro-storming from sepsis in children with TBI.

MATERIALS AND METHODS

A single-institution retrospective review (2014-2021) identified pediatric patients (aged 0-18 y) with moderate-to-severe TBI and intensive care unit admission > 2 d. Patients with multiple febrile events who underwent infectious evaluation including cultures and PCT drawn within 48 h of fever were included. Demographics, vital signs, infectious biomarkers including PCT, and culture data were captured. Univariate and multivariate analyses were performed to determine variables associated with culture positive status.

RESULTS

One hundred and fifty six patients were admitted to the intensive care unit with moderate-to-severe TBI during the study period. Eighty five patients (54%) experienced recurrent febrile episodes. Twenty four (28%) met inclusion criteria, undergoing 32 total infectious workups. Twenty one workups were culture-positive (66%) in a total of 18 patients. Median PCT levels were not statistically different between culture-positive and culture-negative workups (P = 0.94). In multivariate modeling, neither PCT [odds ratio 0.89 (confidence interval: 0.75-1.05)] nor temperature [odds ratio 7.34 (confidence interval: 0.95-57.16)] correlated with positive bacterial cultures.

CONCLUSIONS

In this small pilot analysis, recurrent febrile episodes were common and PCT did not correlate with sepsis or neuro-storming in pediatric TBI patients. Prospective protocols are needed to better understand the utility of PCT and identify predictors of bacterial infection to improve early diagnosis of sepsis in this population.

Weathering the storm: a single-institution experience with paroxysmal sympathetic hyperactivity after brain tumor resection in pediatric patients

OBJECTIVE

Paroxysmal sympathetic hyperactivity (PSH) is a complication of severe traumatic or hypoxic brain injury characterized by transient episodes of tachycardia, tachypnea, hypertension, hyperthermia, diaphoresis, and/or dystonic posturing. Posttraumatic "sympathetic storms" are associated with poor outcomes. PSH rarely occurs after brain tumor resection in pediatric patients; only 4 cases have been published since 1929. Thus, the authors sought to report their experience with postcraniotomy PSH in pediatric brain tumor patients.

METHODS

A retrospective study of patients younger than 18 years of age who underwent craniotomy for brain tumor resection at a single center by a single surgeon over a 7-year period was performed. A clinical diagnosis of postoperative PSH was recorded. Recorded outcomes included the interval between surgery and initiation of cytotoxic therapy, need for long-term CSF diversion, length of hospital stay, and survival.

RESULTS

Of the 150 patients who were included for analysis, 4 patients were diagnosed with postoperative PSH for an overall occurrence of 2.7%. PSH patients were younger than non-PSH patients (1.8 ± 0.4 years vs 9.2 ± 5.3 years, p = 0.010) and tended to have intraventricular tumors close to the thalamus, basal ganglia, and/or brainstem. PSH patients experienced longer hospital admissions (44.3 ± 23.4 days vs 6.8 ± 9.4 days, p = 0.001), a shorter interval between surgery and initiation of cytotoxic cancer-directed therapy (14.3 ± 8.0 days vs 90.7 days ± 232.9 days, p = 0.011), and increased need for long-term CSF diversion compared with non-PSH patients (75% vs 25%, p = 0.005). At the last follow-up, 50% of PSH patients had died compared with 13% of non-PSH patients (p = 0.094).

CONCLUSIONS

PSH is a rare postoperative complication that may affect young children with periventricular tumors and is associated with poorer clinical outcomes. Increasing awareness of this condition is vital to improving patient outcomes.

Paroxysmal Sympathetic Hyperactivity in Neurocritical Children: A Pilot Study

Background

Paroxysmal sympathetic hyperactivity (PSH) is characterized by the abnormal excessive sympathetic response to acute cerebral insult. There is a paucity of data about this condition in children. This study was planned to analyze the incidence of PSH among children requiring neurocritical care and its association with the outcome.

Materials and methods

The study was conducted in the pediatric intensive care unit (PICU) of a tertiary care hospital over a period of 10 months. Children of age 1 month to 12 years admitted with neurocritical illnesses were included. Children who were declared brain dead after initial resuscitation were excluded from the study. The criterion laid by Moeller et al. was used for the diagnosis for PSH.

Results

During the study period, 54 children requiring neurocritical care were included in the study. The incidence of PSH was 5/54 (9.2%). Additionally, 30 (55.5%) children had less than four criteria for PSH and were termed as "incomplete PSH." Children with all four criteria for PSH had a significantly longer duration of mechanical ventilation, PICU stay, and higher PRISM III scores. Children with less than four criteria for PSH also had a longer duration of mechanical ventilation and stay. However, there was no significant difference in mortality.

Conclusion

Paroxysmal sympathetic hyperactivity is common in children with neurological illnesses admitted to the PICU and is associated with longer mechanical ventilation and stay in PICU. They also had higher illness severity scores. Timely diagnosis of the condition and appropriate management is required to improve the outcome of these children.

How to cite this article

Agrwal S, Pallavi, Jhamb U, Saxena R. Paroxysmal Sympathetic Hyperactivity in Neurocritical Children: A Pilot Study. Indian J Crit Care Med 2022;26(11):1204-1209.

Paroxysmal Sympathetic Hyperactivity: It is Time to Use the New Diagnostic Criteria

How to cite this article: Krupanandan R. Paroxysmal Sympathetic Hyperactivity: It is Time to Use the New Diagnostic Criteria. Indian J Crit Care Med 2022;26(11):1165-1166.

Paroxysmal Sympathetic Hyperactivity in Adult Patients with Brain Injury: A Systematic Review and Meta-Analysis

BACKGROUND

Paroxysmal sympathetic hyperactivity (PSH) is a syndrome of excessive sympathetic activity, mainly occurring in severe traumatic brain injury. However, few studies have reported the frequency of PSH and its related risk factors in adult patients with brain injury.

METHODS

We performed this systematic review and meta-analysis to estimate the combined incidence of PSH and the associated risk factors in adult patients with brain injury. This study was registered with the PROSPERO international prospective register of systematic reviews (https://www.crd.york. ac.uk/PROSPERO/Identifier: CRD 42021260493), and a systematic search was conducted of the scientific databases Embase, PubMed, Web of Science, Cochrane Library, and Google Scholar. All identified observational studies regarding the incidence and risk factors of PSH in adult patients with brain injury were included. Two authors extracted data independently; data were analyzed by STATA version 16.

RESULTS

The search yielded 9 studies involving 1643 adult patients. PSH was detected in 438 patients. The combined incidence of PSH in adult patients with brain injury was 27.4% (95% confidence interval [CI], 0.190-0.358). The risk factors include patients' age (SMD = -0.592; I² = 77.5%; 95% CI, -1.027 to -0.156; P = 0.008), traffic accident (odds ratio [OR], 1.783; I² =18.0%; 95% CI, 1.128-2.820; P = 0.013), admission Glasgow Coma Scale score (SMD = -1.097; I² =28.3%; 95% CI, -1.500 to -0.693; P = 0.000), hydrocephalus (OR, 3.936; I² =67.9%; 95% CI, 1.144-13.540; P = 0.030), and diffuse axonal injury (OR, 4.747; I² =71.1%; 95% CI, 1.221-18.463; P = 0.025) and were significantly associated with the presence of PSH after brain injury.

CONCLUSIONS

PSH occurs in nearly a quarter of adult patients with brain injury. Patient's age, traffic accident, admission Glasgow Coma Scale score, hydrocephalus, and diffuse axonal injury were risk factors for PSH in adult patients with brain injury. These findings may contribute to novel strategies for early diagnosis and interventions that aid in the rehabilitation of patients with brain injury.

Characteristics and Outcomes of Paroxysmal Sympathetic Hyperactivity in Anti-NMDAR Encephalitis

Background

To explore the clinical characteristics and prognosis of autonomic dysfunction and paroxysmal sympathetic hyperactivity (PSH), and evaluate the efficacy of drugs used to suppress PSH episode in anti-NMDAR encephalitis patients.

Methods

Patients who met the diagnostic criteria of anti-NMDAR encephalitis were enrolled from January 2012 to August 2018 and followed up for 2 years. PSH was diagnosed according to the PSH-Assessment Measure. The demographics data, clinical features, auxiliary tests results, treatments, and outcomes were prospective collected and analyzed.

Results

A total of 132 anti-NMDAR encephalitis patients were enrolled, of which 27.3% and 9.1% experienced autonomic dysfunction and probable PSH respectively. Cardiac autonomic dysfunction was the most common subtype (77.8%). Patients with a higher incidence of ovarian teratoma, mechanical ventilation, neurological intensive care unit admission, and elevated glucose and NMDAR antibody titer in the CSF were more likely to exhibit autonomic dysfunction or PSH. Episodes of PSH can be suppressed by monotherapy in patients without prior sedative drug use with an efficacy of 90%. No significant difference was observed between the prognosis of patients with or without autonomic dysfunction, or between the PSH versus non-PSH groups after 6 months and even during long-term follow-up. However, patients with cardiac autonomic dysfunction had poor prognosis at 6 months.

Conclusion

PSH is a common clinical condition in patients with anti-NMDAR encephalitis, especially in severe cases, and can be effectively managed by several drug monotherapies. Despite necessitating longer hospital stay, autonomic dysfunction or PSH do not seem to compromise the neurological recovery of patients.

Pediatric severe traumatic brain injury mortality prediction determined with machine learning-based modeling

INTRODUCTION

Severe traumatic brain injury (sTBI) is a leading cause of mortality in children. As clinical prognostication is important in guiding optimal care and decision making, our goal was to create a highly discriminative sTBI outcome prediction model for mortality.

METHODS

Machine learning and advanced analytics were applied to the patient admission variables obtained from a comprehensive pediatric sTBI database. Demographic and clinical data, head CT imaging abnormalities and blood biochemical data from 196 children and adolescents admitted to a tertiary pediatric intensive care unit (PICU) with sTBI were integrated using feature ranking by way of a forest of randomized decision trees, and a model was generated from a reduced number of admission variables with maximal ability to discriminate outcome.

RESULTS

In total, 36 admission variables were analyzed using feature ranking with variable weighting to determine their predictive importance for mortality following sTBI. Reduction analysis utilizing Borata feature selection resulted in a parsimonious six-variable model with a mortality classification accuracy of 82%. The final admission variables that predicted mortality were: partial thromboplastin time (22%); motor Glasgow Coma Scale (21%); serum glucose (16%); fixed pupil(s) (16%); platelet count (13%) and creatinine (12%). Using only these six admission variables, a t-distributed stochastic nearest neighbor embedding algorithm plot demonstrated visual separation of sTBI patients that lived or died, with high mortality predictive ability of this model on the validation dataset (AUC = 0.90) which was confirmed with a conventional area-under-the-curve statistical approach on the total dataset (AUC = 0.91; P < 0.001).

CONCLUSIONS

Machine learning-based modeling identified the most clinically important prognostic factors resulting in a pragmatic, high performing prognostic tool for pediatric sTBI with excellent discriminative ability to predict mortality risk with 82% classification accuracy (AUC = 0.90). After external multicenter validation, our prognostic model might help to guide treatment decisions, aggressiveness of therapy and prepare family members and caregivers for timely end-of-life discussions and decision making.

LEVEL OF EVIDENCE

III; Prognostic.

Paroxysmal Sympathetic Hyperactivity in Moderate-to-Severe Traumatic Brain Injury and the Role of Beta-Blockers: A Scoping Review

Introduction

Most cases of paroxysmal sympathetic hyperactivity (PSH) result from traumatic brain injury (TBI). Little is known about its pathophysiology and treatment, and several neuroprotective drugs are used including beta-blockers. The aim of our study is to collate existing evidence of the role of beta-blockers in the treatment of PSH.

Methods

We searched MEDLINE, ResearchGate, and Google Scholar, for keywords related to PSH and the role of beta-blockers in moderate-to-severe TBI on September 23, 2020. Two authors blindly screened the articles found with Rayyan. Both resolved their conflicts by mutual consent. If no solution was found, a third author was consulted. Simple descriptive data analysis was performed and the results were presented both in a narrative and tabular form.

Results

Of the 19 items found, 10 met the criteria for inclusion. 50% were systematic reviews without meta-analysis, 40% were observational studies, and 10% were experimental studies. Propranolol was the main beta-blocker found in 80% of the studies and was the only molecule used in the treatment of paroxysmal sympathetic hyperactivity in 40% of the included studies. Only two studies evaluated and showed a significant association between beta-blockers and mortality rate (5.1% vs. 10.8%; P=0.03), (3% vs. 15%; P=0.002), respectively.

Conclusion

Propranolol is the beta-blocker that has been shown to be effective in reducing the length of stay and mortality rate in moderate-severe traumatic brain injury patients with PSH. However, further studies are needed to precisely define the terms and conditions of its use.

β-Blockers for traumatic brain injury: A systematic review and meta-analysis

BACKGROUND

Paroxysmal sympathetic hyperactivity (PSH) and catecholamine surge, which are associated with poor outcome, may be triggered by traumatic brain injury (TBI).β Adrenergic receptor blockers (β-blockers), as potential therapeutic agents to prevent paroxysmal sympathetic hyperactivity and catecholamine surge, have been shown to improve survival after TBI. The principal aim of this study was to investigate the effect of β-blockers on outcomes in patients with TBI.

METHODS

For this systematic review and meta-analysis, we searched MEDLINE, EMBASE, and Cochrane Library databases from inception to September 25, 2020, for randomized controlled trials, nonrandomized controlled trials, and observational studies reporting the effect of β-blockers on the following outcomes after TBI: mortality, functional measures, and cardiopulmonary adverse effects of β-blockers (e.g., hypotension, bradycardia, and bronchospasm). With use of random-effects model, we calculated pooled estimates, confidence intervals (CIs), and odds ratios (ORs) of all outcomes.

RESULTS

Fifteen studies with 12,721 patients were included. Exposure to β-blockers after TBI was associated with a significant reduction in adjusted in-hospital mortality (OR, 0.39; 95% CI, 0.30-0.51; I2 = 66.3%; p < 0.001). β-Blockers significantly improved the long-term (≥6 months) functional outcome (OR, 1.75; 95% CI, 1.09-2.80; I2 = 0%; p = 0.02). Statistically significant difference was not seen for cardiopulmonary adverse events (OR, 0.91; 95% CI, 0.55-1.50; I2 = 25.9%; p = 0.702).

CONCLUSION

This meta-analysis demonstrated that administration of β-blockers after TBI was safe and effective. Administration of β-blockers may therefore be suggested in the TBI care. However, more high-quality trials are needed to investigate the use of β-blockers in the management of TBI.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level III.

Paroxysmal sympathetic hyperactivity following status epilepticus in a 22-year-old with Juvenile Neuronal Ceroid Lipofuscinosis: A case report

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Late sequalae of juvenile neuronal ceroid lipofuscinosis are seen in older patients.

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Status epilepticus may incite paroxysmal sympathetic hyperactivity in JNCL.

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PSH may be clinically confused with seizures in JNCL complicated by epilepsy.

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PSH can be found in a patient with JNCL without infection or inciting factors.

The Neuronal Ceroid Lipofuscinosis (NCL) refers to a group of rare neurolipidosis disorders characterized by progressive blindness, deterioration of speech and motor function, cognitive decline, behavior problems, seizures, and premature death. We report a case of a 22-year-old man with CLN3 variant, homozygous NCL (aka Juvenile Neuronal Ceroid Lipofuscinosis) complicated by epilepsy who presented with episodes of recurrent seizure-like activity following status epilepticus, but now without electrographic correlate. Episodes were accompanied by tachycardia, diaphoresis, hypertension, and a fearful facial expression likely representing paroxysmal sympathetic hyperactivity (PSH), and improved with administration of propranolol. It is possible that status epilepticus provoked these episodes of PSH.

Development of a Mortality Prediction Tool in Pediatric Severe Traumatic Brain Injury

Severe traumatic brain injury (sTBI) is a leading cause of pediatric death, yet outcomes remain difficult to predict. The goal of this study was to develop a predictive mortality tool in pediatric sTBI. We retrospectively analyzed 196 patients with sTBI (pre-sedation Glasgow Coma Scale [GCS] score <8 and head Maximum Abbreviated Injury Scale (MAIS) score >4) admitted to a pediatric intensive care unit (PICU). Overall, 56 patients with sTBI (29%) died during PICU stay. Of the survivors, 88 (63%) were discharged home, and 52 (37%) went to an acute care or rehabilitation facility. Receiver operating characteristic (ROC) curve analyses of admission variables showed that pre-sedation GCS score, Rotterdam computed tomography (CT) score, and partial thromboplastin time (PTT) were fair predictors of PICU mortality (area under the curve [AUC] = 0.79, 0.76, and 0.75, respectively; p < 0.001). Cutoff values best associated with PICU mortality were pre-sedation GCS score <5 (sensitivity = 0.91, specificity = 0.54), Rotterdam CT score >3 (sensitivity = 0.84, specificity = 0.53), and PTT >34.5 sec (sensitivity = 0.69 specificity = 0.67). Combining pre-sedation GCS score, Rotterdam CT score, and PTT in ROC curve analysis yielded an excellent predictor of PICU mortality (AUC = 0.91). In summary, pre-sedation GCS score (<5), Rotterdam CT score (>3), and PTT (>34.5 sec) obtained on hospital admission were fair predictors of PICU mortality, ranked highest to lowest. Combining these three admission variables resulted in an excellent pediatric sTBI mortality prediction tool for further prospective validation.

Effectiveness of Pharmacological Agents and Validation of Diagnostic Scales for the Management of Paroxysmal Sympathetic Hyperactivity in Hispanics

The identification and treatment of paroxysmal sympathetic hyperactivity (PSH) still present a significant challenge. We assessed the efficacy of pharmacological agents in treating PSH symptoms and the validity of the diagnostic scales in a cohort of Hispanic patients. A retrospective chart review of cases from a single hospital was conducted in 464 records. Exclusion criteria included underlying conditions such as severe infection. Only nine patients remained in the cohort after examining their clinical records, corresponding to the following diagnoses: traumatic brain injury, subdural hemorrhage, anoxic or ischemic encephalopathy, pneumocephalus, and cerebral palsy. Using the PSH likelihood scale, six of the nine patients were identified with a score of 17 or higher, corresponding to a "probable" PSH, and three patients obtained a score between 8 and 16, corresponding to a "possible" PSH diagnosis. The top three classes of medications used were beta-blockers, antipyretics, and opioids. Benzodiazepines and neuromodulators were also frequently used in patients with trauma, but not in the ones with non-traumatic injuries. Interestingly, 75% of the patients have prescribed levothyroxine as a home medication after the PSH presentation. Medication administration did not follow a specific pattern, suggesting high variability in the management of PSH within our setting, requiring further research. Our results suggest that the pituitary axis might be involved in the progression of PSH. Establishing a specific medical code (e.g., ICD-10) describing PSH as a single entity is essential for appropriate identification and management.

Autonomic Hyperactivity

PURPOSE OF REVIEW

Autonomic hyperactivity is a relatively common consequence of severe acute brain injury and can also be seen with spinal cord and peripheral nerve disorders. This article reviews basic pathophysiologic concepts regarding autonomic hyperactivity, its various forms of clinical presentation, and practical management considerations.

RECENT FINDINGS

Paroxysmal sympathetic hyperactivity is most common after traumatic brain injury but can also occur after other forms of severe acute diffuse or multifocal brain injury. Formal criteria for the diagnosis and severity grading of paroxysmal sympathetic hyperactivity have now been proposed. A growing body of literature is beginning to elucidate the mechanisms underlying this disorder, but treatment remains based on observational data. Our mechanistic understanding of other distinct forms of autonomic hyperactivity, such as autonomic dysreflexia after traumatic spinal cord injury and dysautonomia after Guillain-Barré syndrome, remains rudimentary, yet clinical experience shows that their appropriate management can minimize the risk of serious complications.

SUMMARY

Syndromes of autonomic hyperactivity can result from injury at all levels of the neuraxis. Much more research is needed to refine our understanding of these disorders and guide optimal management decisions.

The utility of heart rate variability as a prognostic factor in children with traumatic brain injury

OBJECTIVE

This study aimed to do a literature review to prove the hypothesis that a change in autonomous nervous system regulation, more precisely a decrease in heart rate variability (HRV), is associated with a worse outcome and could be used as a prognostic factor in children with TBI.

METHODS

Databases (Pubmed, World of Science and Scopus) studies were conducted from 1996 to 2017, considering HRV in children with TBI. Seven studies were analyzed.

RESULTS

Patients that became brain dead had a markedly lower LF/HF ratio, with a significant decrease after the first few hours of hospitalization. Patients with a more favorable prognosis had significantly higher LF/HF ratios.

DISCUSSION

The HRV can be useful when determining the severity of neurological damage and a prognostic factor in the evaluation of its recovery. However, to assess the true value of HRV monitoring in children with TBI, a prospective study with identified thresholds for HRV, comparison to the standard methods of assessment and predictions should be made blinded to outcome at admission and then through the clinical course including the post-acute phase of rehabilitation. In the absence of this, any recommendation for its use as a prognostic tool may be premature.

Paroxysmal Sympathetic Hyperactivity

Paroxysmal sympathetic hyperactivity (PSH) is a relatively common, but often unrecognized, complication of acute diffuse or multifocal brain diseases, most frequently encountered in young comatose patients with severe traumatic brain injury. It is presumed to be caused by loss of cortical inhibitory modulation of diencephalic and brain stem centers and possible additional maladaptive changes in the spinal cord that combine to produce exaggerated sympathetic responses to stimulation. The syndrome consists of repeated sudden episodes of tachycardia, tachypnea, hypertension, sweating, and sometimes fever and dystonic posturing. The diagnosis is clinical. Treatment includes reducing any external stimulation that can trigger the episodes, and starting abortive (e.g., intravenous morphine) and preventive medications (e.g., gabapentin, propranolol, clonidine). Prompt and adequate treatment of PSH may reduce the likelihood of secondary complications, such as dehydration, weight loss and malnutrition, and muscle contractures.

Non-neurologic organ dysfunction plays a major role in predicting outcomes in pediatric traumatic brain injury

BACKGROUND

Nonneurological organ dysfunction (NNOD) occurs after traumatic brain injury (TBI) and is associated with mortality. The aim of our study was to evaluate the prevalence of NNOD and its association with outcomes in pediatric patients with TBI. We hypothesized that NNOD is associated with worse outcomes in pediatric patients with severe TBI.

METHODS

We performed a 4-year (2013-16) analysis of our prospectively maintained TBI database. All patients (age < 18) with an isolated-severe TBI (head-abbreviated injury scale: AIS ≥ 3 & extracranial-AIS < 3) were included. NNOD was measured using the pediatric multiple organ dysfunction (P-MOD) score. Outcomes were in-hospital mortality, Glasgow Outcome Scale-Extended (GOS-E), and adverse discharge disposition: rehabilitation or skilled nursing facility (SNF). Regression analysis was performed.

RESULTS

We analyzed 292 patients. Mean age was 11 ± 6 years, 57% were male and the mortality rate was 18.1%. The incidence of NNOD was 35%. The most common dysfunctional organ system was the respiratory (25%) followed by the cardiovascular (12%). On regression analysis, the presence of at least one NNOD was independently associated with in-hospital mortality (OR 2.1 [1.7-2.9]; p < 0.01), low GOS-E (OR 1.8 [1.5-2.3]; p < 0.01), and SNF disposition (OR 1.7 [1.2-2.1]; p < 0.01).

CONCLUSION

NNOD develops in one of every three severe TBI pediatric patients and is independently associated with adverse outcomes. Identification of NNOD in pediatric TBI and focusing on management of NNOD could improve outcomes.

LEVEL OF EVIDENCE

III Prognostic.

Identification and Management of Paroxysmal Sympathetic Hyperactivity After Traumatic Brain Injury

Paroxysmal sympathetic hyperactivity (PSH) has predominantly been described after traumatic brain injury (TBI), which is associated with hyperthermia, hypertension, tachycardia, tachypnea, diaphoresis, dystonia (hypertonia or spasticity), and even motor features such as extensor/flexion posturing. Despite the pathophysiology of PSH not being completely understood, most researchers gradually agree that PSH is driven by the loss of the inhibition of excitation in the sympathetic nervous system without parasympathetic involvement. Recently, advances in the clinical and diagnostic features of PSH in TBI patients have reached a broad clinical consensus in many neurology departments. These advances should provide a more unanimous foundation for the systematic research on this clinical syndrome and its clear management. Clinically, a great deal of attention has been paid to the definition and diagnostic criteria, epidemiology and pathophysiology, symptomatic treatment, and prevention and control of secondary brain injury of PSH in TBI patients. Potential benefits of treatment for PSH may result from the three main goals: eliminating predisposing causes, mitigating excessive sympathetic outflow, and supportive therapy. However, individual pathophysiological differences, therapeutic responses and outcomes, and precision medicine approaches to PSH management are varied and inconsistent between studies. Further, many potential therapeutic drugs might suppress manifestations of PSH in the process of TBI treatment. The purpose of this review is to present current and comprehensive studies of the identification of PSH after TBI in the early stage and provide a framework for symptomatic management of TBI patients with PSH.

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

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.

Mortality And Morbidity of Severe Traumatic Brain Injuries; A Pediatric Intensive Care Unit Experience Over 15 Years

Objective

To determine the mortality, morbidity, types of intracranial hemorrhages, and factors associated with length of stay (LOS) associated with accidental traumatic brain injury (TBI) at a pediatric intensive care unit (PICU) of a regional trauma center in an Asian city.

Methods

This study is a retrospective review of types of head injury, mortality and morbidity demographics of patients admitted to a PICU with TBI. All patients with accidental TBI were included, namely road traffic injury (RTI) and fall, and their demographics compared. Non-accidental injuries (NAI) were excluded.

Results

95 children (78% males) were admitted to a PICU with RTI or falls from 2002 to 2017. They accounted for 3.7% of PICU admissions. Comparing with falls, victims of RTI were older (p<0.001) and more likely to suffer from skull fracture (p=0.017). There were 4 deaths with falls (6.8%) but none with RTI. Subarachnoid hemorrhages, extradural hemorrhages, the use of mechanical ventilation, inotropes and neurological supports were associated with longer LOS in PICU in these injuries (p<0.001).

Conclusion

A longer PICU LOS is associated with extradural and subarachnoid hemorrhages, usage of inotropes, mechanical ventilation and neurological supports in falls and RTI. Three-quarters of victims are males. Preventive health education should be especially directed to boys to reduce severe TBI in this Asian city.

Effects of dexmedetomidine vs sufentanil during percutaneous tracheostomy for traumatic brain injury patients: A prospective randomized controlled trial

BACKGROUND

Percutaneous tracheostomy, almost associated with cough reflex and hemodynamic fluctuations, is a common procedure for traumatic brain injury (TBI) patients, especially those in neurosurgery intensive care units (NICUs). However, there are currently a lack of effective preventive measures to reduce the risk of secondary brain injury. The aim of this study was to compare the effect of dexmedetomidine (DEX) vs sufentanil during percutaneous tracheostomy in TBI patients.

METHODS

The 196 TBI patients who underwent percutaneous tracheostomy were randomized divided into 3 groups: group D1 (n = 62, DEX infusion at 0.5 μg·kg for 10 minutes, then adjusted to 0.2-0.7 μg·kg·hour), group D2 (n = 68, DEX infusion at 1 μg·kg for 10 minutes, then adjusted to 0.2-0.7 μg·kg·hour), and group S (n = 66, sufentanil infusion 0.3 μg·kg for 10 minutes, then adjusted to 0.2-0.4 μg·kg·hour). The bispectral index (BIS) of all patients was maintained at 50 to 70 during surgery. Anesthesia onset time, hemodynamic variables, total cumulative dose of DEX/sufentanil, total doses of rescue propofol and fentanyl, time to first dose of rescue propofol and fentanyl, number of intraoperative patient movements and cough reflexes, adverse events, and surgeon satisfaction score were recorded.

RESULTS

Anesthesia onset time was significantly lower in group D2 than in both other groups (14.35 ± 3.23 vs 12.42 ± 2.12 vs 13.88 ± 3.51 minutes in groups D1, D2, and S, respectively; P < .001). Both heart rate and mean arterial pressure during percutaneous tracheostomy were more stable in group D2. Total doses of rescue propofol and fentanyl were significantly lower in group D2 than in group D1 (P < .001). The time to first dose of rescue propofol and fentanyl were significantly longer in group D2 than in both other groups (P < .001). The number of patient movements and cough reflexes during percutaneous tracheostomy were lower in group D2 than in both other groups (P < .001). The overall incidences of tachycardia and hypertension (which required higher doses of esmolol and urapidil, respectively) were also lower in group D2 than in both other groups (P < .05). Three patients in group S had respiratory depression compared to X in the D1 group and X in the D2 group. The surgeon satisfaction score was significantly higher in group D2 than in both other groups (P < .05).

CONCLUSIONS

During percutaneous tracheostomy, compared with sufentanil, DEX (1 μg·kg for 10 minutes, then adjusted to 0.2-0.7 μg·kg·hour) can provide the desired attenuation of the hemodynamic response without increased adverse events. Consequently, DEX could be used safely and effectively during percutaneous tracheostomy in TBI patients.