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Agrwal S, Pallavi, Jhamb U, Saxena R. Author Response. Indian J Crit Care Med 2024; 28:518-519. [PMID: 38738187 PMCID: PMC11080092 DOI: 10.5005/jp-journals-10071-24703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024] Open
Abstract
How to cite this article: Agrwal S, Pallavi, Jhamb U, Saxena R. Author Response. Indian J Crit Care Med 2024;28(5):518-519.
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Affiliation(s)
- Shipra Agrwal
- Department of Pediatrics, ESIC Medical College and Hospital, Faridabad, Haryana, India
| | - Pallavi
- Department of Pediatrics, Maulana Azad Medical College, New Delhi, India
| | - Urmila Jhamb
- Department of Pediatrics, Maulana Azad Medical College, New Delhi, India
| | - Romit Saxena
- Department of Pediatrics, Maulana Azad Medical College, New Delhi, India
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2
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Nguyen TL, Simon DW, Lai YC. Beyond the brain: General intensive care considerations in pediatric neurocritical care. Semin Pediatr Neurol 2024; 49:101120. [PMID: 38677799 DOI: 10.1016/j.spen.2024.101120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/29/2024] [Accepted: 03/10/2024] [Indexed: 04/29/2024]
Abstract
Managing children with critical neurological conditions requires a comprehensive understanding of several principles of critical care. Providing a holistic approach that addresses not only the acute interactions between the brain and different organ systems, but also critical illness-associated complications and recovery is essential for improving outcomes in these patients. The brain reacts to an insult with autonomic responses designed to optimize cardiac output and perfusion, which can paradoxically be detrimental. Managing neuro-cardiac interactions therefore requires balancing adequate cerebral perfusion and minimizing complications. The need for intubation and airway protection in patients with acute encephalopathy should be individualized following careful risk/benefit deliberations. Ventilatory strategies can have profound impact on cerebral perfusion. Therefore, understanding neuro-pulmonary interactions is vital to optimize ventilation and oxygenation to support a healing brain. Gastrointestinal dysfunction is common and often complicates the care of patients with critical neurological conditions. Kidney function, along with fluid status and electrolyte derangements, should also be carefully managed in the acutely injured brain. While in the pediatric intensive care unit, prevention of critical illness-associated complications such as healthcare-associated infections and deep vein thrombosis is vital in improving outcomes. As the brain emerges from the acute injury, rehabilitation and management of delirium and paroxysmal sympathetic hyperactivity is paramount for optimal recovery. All these considerations provide a foundation for the care of pediatric patients with critical neurological conditions in the intensive care unit.
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Affiliation(s)
- Thao L Nguyen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, McGovern Medical School, UT Health Houston, Houston, TX
| | - Dennis W Simon
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Yi-Chen Lai
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX.
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Wu W. Symptom Management in Children Who Are Neurologically Impaired for the Primary Care Medical Home. Pediatr Ann 2024; 53:e82-e87. [PMID: 38466328 DOI: 10.3928/19382359-20240108-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
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.].
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Xu SY, Zhang Q, Li CX. Paroxysmal Sympathetic Hyperactivity After Acquired Brain Injury: An Integrative Review of Diagnostic and Management Challenges. Neurol Ther 2024; 13:11-20. [PMID: 37948005 PMCID: PMC10787720 DOI: 10.1007/s40120-023-00561-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/23/2023] [Indexed: 11/12/2023] Open
Abstract
Paroxysmal sympathetic hyperactivity (PSH) mainly occurs after acquired brain injury (ABI) and often presents with high fever, hypertension, tachycardia, tachypnea, sweating, and dystonia (increased muscle tone or spasticity). The pathophysiological mechanisms of PSH are not fully understood. Currently, there are several views: (1) disconnection theory, (2) excitatory/inhibitory ratio, (3) neuroendocrine function, and (4) neutrophil extracellular traps. Early diagnosis of PSH remains difficult, given the low specificity of its diagnostic tools and unclear pathogenesis. According to updated case analyses in recent years, PSH is now more commonly observed in patients with stroke, with tachycardia and hypertension as the main clinical manifestations, which is not fully consistent with previous data. To date, the PSH Assessment Measure tool is optimal for the early identification of PSH and stratification of symptom severity. Clinical strategies for the management of PSH are divided into three main points: (1) reduction of stimulation, (2) reduction of sympathetic excitatory afferents, and (3) inhibition of the effects of sympathetic hyperactivity on target organs. However, use of drugs and standards have not yet been harmonized. Further investigation on the relationship between PSH severity and long-term neurological prognosis in patients with ABI is required. This review aimed to determine the diagnostic and management challenges encountered in PSH after ABI.
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Affiliation(s)
- Sui-Yi Xu
- Department of Neurology, Headache Center, The First Hospital of Shanxi Medical University, Jiefangnan 85 Road, 030001, Taiyuan, Shanxi, People's Republic of China
| | - Qi Zhang
- Department of Neurology, Headache Center, The First Hospital of Shanxi Medical University, Jiefangnan 85 Road, 030001, Taiyuan, Shanxi, People's Republic of China
| | - Chang-Xin Li
- Department of Neurology, Headache Center, The First Hospital of Shanxi Medical University, Jiefangnan 85 Road, 030001, Taiyuan, Shanxi, People's Republic of China.
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Carozza RB, Mohanty D, Wolf MS, Martin EN, Anderson J, Pagano LM. Paroxysmal Sympathetic Hyperactivity: Development of a Pediatric Clinical Practice Guideline. Hosp Pediatr 2023; 13:e402-e410. [PMID: 37953681 DOI: 10.1542/hpeds.2023-007261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Affiliation(s)
| | | | | | | | - Jessica Anderson
- Department of Pharmacy, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee
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Lotakis D, Vernamonti J, Ehrlich P, Gadepalli S. Procalcitonin and Pediatric Traumatic Brain Injury: Differentiating Neuro-Storming From Infection. J Surg Res 2023; 289:129-134. [PMID: 37104923 DOI: 10.1016/j.jss.2023.03.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/25/2023] [Accepted: 03/30/2023] [Indexed: 04/29/2023]
Abstract
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.
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Affiliation(s)
- Dimitra Lotakis
- Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan.
| | - Jack Vernamonti
- Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Peter Ehrlich
- Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Samir Gadepalli
- Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
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Pentony M, Featherstone M, Sheikh Y, Stroiescu A, Bruell H, Gill I, Gorman KM. Dystonia in children with acquired brain injury. Eur J Paediatr Neurol 2022; 41:41-47. [PMID: 36209658 DOI: 10.1016/j.ejpn.2022.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/25/2022] [Accepted: 09/22/2022] [Indexed: 01/11/2023]
Abstract
AIM To quantify the proportion of children who develop dystonia after acquired brain injury (ABI) admitted to a tertiary paediatric intensive care unit (PICU) and analyse the trajectory of dystonia over a 6 month period. METHODS Children's Health Ireland at Temple Street PICU electronic database was searched for key terms related to ABI from January 1, 2016 to March 14, 2021. Individuals meeting inclusion criteria were analysed, and clinical data pertinent to ABI, dystonia, treatment and outcomes were reviewed. RESULTS Six-hundred and forty-three PICU episodes (580 patients) met search criteria for ABI, with 379 included in the final analysis. Twelve patients developed dystonia following ABI, giving an incidence of 3.2%. The incidence was higher in the hypoxia/anoxia and TBI cohort at 8.3% and 6.2%, respectively. All patients developed dystonia within the first month following ABI (50% by a week). Patients who developed dystonia compared to non-dystonia cohort had a median lower GCS on admission (4.5 versus 7.0, p value 0.032), longer median length of PICU stay (14.0 versus 3.0 days, p value < 0.001) and were older (median age 9.08 versus 4.68 years, p value 0.06). Dystonia persisted in the majority at 6 months (10/11), requiring on-going medical therapies. CONCLUSION In our retrospective study, the estimated incidence of dystonia following ABI admitted to the PICU was 3.2%, highest in the hypoxia/anoxia (8.3%) and TBI (6.2%) cohorts. Dystonia emerged early and persisted at 6 months in the majority. This is the first review of dystonia, clinical trajectory and outcomes conducted post-PICU admission for ABI. Future prospective studies are required to determine the true prevalence and burden of disease in the PICU setting.
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Affiliation(s)
- M Pentony
- Department of Neurology and Clinical Neurophysiology, Children's Health Ireland at Temple Street, Ireland
| | - M Featherstone
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - Y Sheikh
- Department of Paediatric Radiology, Children's Health Ireland at Temple Street, Ireland
| | - A Stroiescu
- Department of Paediatric Radiology, Children's Health Ireland at Temple Street, Ireland
| | - H Bruell
- Department of Paediatric Intensive Care, Children's Health Ireland at Temple Street, Ireland
| | - I Gill
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland; Department of Neurodisability, Children's Health Ireland at Temple Street, Ireland; Department of Paediatric Rehabilitation, National Rehabilitation Hospital, Dublin, Ireland
| | - K M Gorman
- Department of Neurology and Clinical Neurophysiology, Children's Health Ireland at Temple Street, Ireland; School of Medicine and Medical Science, University College Dublin, Dublin, Ireland.
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Agrwal S, Pallavi, Jhamb U, Saxena R. Paroxysmal Sympathetic Hyperactivity in Neurocritical Children: A Pilot Study. Indian J Crit Care Med 2022; 26:1204-1209. [PMID: 36873585 PMCID: PMC9983649 DOI: 10.5005/jp-journals-10071-24346] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 09/27/2022] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Shipra Agrwal
- Department of Pediatrics, Army College of Medical Sciences, New Delhi, India
| | - Pallavi
- Department of Pediatrics, Maulana Azad Medical College, New Delhi, India
| | - Urmila Jhamb
- Department of Pediatrics, Maulana Azad Medical College, New Delhi, India
| | - Romit Saxena
- Department of Pediatrics, Maulana Azad Medical College, New Delhi, India
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Lumsden DE. Dystonia following acquired brain injury (ABI) in childhood - Not as common as we might think? Eur J Paediatr Neurol 2022; 41:A4. [PMID: 36400624 DOI: 10.1016/j.ejpn.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Daniel E Lumsden
- Complex Motor Disorder Service, Children's Neurosciences, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, West Mininister Bridge Road, London, SE1 7EH, UK.
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Krupanandan R. Paroxysmal Sympathetic Hyperactivity: It is Time to Use the New Diagnostic Criteria. Indian J Crit Care Med 2022; 26:1165-1166. [PMID: 36873596 PMCID: PMC9983648 DOI: 10.5005/jp-journals-10071-24359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 10/25/2022] [Indexed: 11/05/2022] Open
Abstract
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.
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Affiliation(s)
- Ravikumar Krupanandan
- Department of Pediatric Intensive Care Unit, Kanchi Kamakoti Childs Trust Hospital, Chennai, Tamil Nadu, India
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Qian J, Min X, Wang F, Xu Y, Fang W. Paroxysmal Sympathetic Hyperactivity in Adult Patients with Brain Injury: A Systematic Review and Meta-Analysis. World Neurosurg 2022; 166:212-219. [PMID: 35398326 DOI: 10.1016/j.wneu.2022.03.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Jiawei Qian
- Department of Neurosurgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaoqiang Min
- College of Pharmaceutical Science, Zhejiang University of Technology, Hangzhou, China
| | - Feng Wang
- Department of Neurosurgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yuanhua Xu
- Department of Neurosurgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wenchao Fang
- Department of Neurosurgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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Khandelwal A, Nayak S, Rajagopalan V, Rath G, Routaray S. Paroxysmal sympathetic hyperactivity after severe traumatic brain injury in children: A retrospective case series. J Pediatr Neurosci 2022. [DOI: 10.4103/jpn.jpn_218_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Berg AT, Coffman K, Gaebler-Spira D. Dysautonomia and functional impairment in rare developmental and epileptic encephalopathies: the other nervous system. Dev Med Child Neurol 2021; 63:1433-1440. [PMID: 34247387 DOI: 10.1111/dmcn.14990] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/16/2021] [Indexed: 12/27/2022]
Abstract
AIM To determine whether functional impairments and autonomic symptoms are correlated in young people with developmental and epileptic encephalopathies (DEEs). METHOD Cross-sectional, online surveys (2018-2020) of parents recruited from family groups obtained information on several aspects of children's conditions including functional abilities (mobility, hand use, eating, and communication), 18 autonomic symptoms in six groups (cardiac, respiratory, sweating, temperature, gastrointestinal, and other), and parental stress. Bivariate and multivariable logistic regression analyses examined associations of dysautonomias with functional impairment, adjusted for type of DEE and age. RESULTS Of 313 participants with full information on function and dysautonomias, 156 (50%) were females. The median age was 8 years (interquartile range 4-12y); 255 (81%) participants had symptoms in at least one autonomic symptom group; 283 (90%) had impairment in at least one functional domain. The number of functional impairment domains and of autonomic symptom groups varied significantly across DEE groups (both p<0.001). The number of functional impairment domains and of autonomic symptom groups were correlated (Spearman's r=0.35, p<0.001) on bivariate and multivariable analysis adjusted for DEE group and age. Parental stress was also independently correlated with dysautonomias (p<0.001). INTERPRETATION Parent-reported dysautonomias are common in children with DEEs. They correlate with extent of functional impairment and may contribute to caregiver stress. What this paper adds Dysautonomic symptoms are common in young people with developmental and epileptic encephalopathies (DEEs). Burden of dysautonomias is strongly correlated with burden of functional impairments. Aspects of dysautonomic function may provide biomarkers of DEE disease severity.
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Affiliation(s)
- Anne T Berg
- Division of Neurology, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Department of Pediatrics, Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - Keith Coffman
- Division of Neurology, Department of Pediatrics, Children's Mercy, Kansas City, MO, USA
| | - Deborah Gaebler-Spira
- Shirley Ryan Ability Lab, Chicago, IL, USA.,Department of Physical Medicine and Rehabilitation, Northwestern Feinberg School of Medicine, Chicago, IL, USA.,Department of Pediatrics, Northwestern Feinberg School of Medicine, Chicago, IL, USA
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Taira R, Yamamura K, Maeda T, Sakata A, Watanabe E, Shimogawa T, Mukae N, Ikeda C, Migita M, Watanabe O, Koga Y, Sakai Y, Ohga S. Paroxysmal sympathetic hyperactivity and the later development of epilepsy in a chemotherapy-associated brain damage. Brain Dev 2021; 43:1044-1050. [PMID: 34301435 DOI: 10.1016/j.braindev.2021.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/21/2021] [Accepted: 07/04/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chemotherapy in childhood leukemia potentially induces brain lesions and neurological sequelae. Paroxysmal sympathetic hyperactivity (PSH) is known as a treatment-associated complication; however, the full clinical spectra of PSH remain to be elusive. CASE REPORT A 5-year-old girl was diagnosed of acute myeloid leukemia (AML) M5. After the intensification therapy, she developed recurrent symptoms of episodic tachycardia, hypertension and perspiration lasting for several hours per day. The low-frequency-high-frequency ratio on Holter electrocardiography was rapidly increased from 0.84 to 2.24 at the onset of the paroxysmal event, whereas the video-monitoring electroencephalography (EEG) never identified ictal patterns of epileptiform discharges during the episodes. Thus, the diagnosis of PSH was given at 7 years of age. Myoclonic and generalized tonic-clonic seizures frequently appeared from 10 years of age, which poorly responded to anticonvulsants. EEG showed diffuse slow-wave bursts with multifocal spikes. Serial head magnetic resonance imaging (MRI) revealed diffuse cerebral and hippocampal atrophy, but not inflammatory lesions in the limbic system. CONCLUSION We first demonstrate a pediatric case with PSH who developed drug-resistant epilepsy 3 years after the onset of PSH. Our data suggest the pathophysiological link of persistent PSH with chemotherapy-associated brain damage.
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Affiliation(s)
- Ryoji Taira
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenichiro Yamamura
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Perinatal and Pediatric Medicine, Kyushu University, Fukuoka, Japan
| | - Tomoko Maeda
- Department of Clinical Chemistry and Laboratory Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Ayumi Sakata
- Department of Clinical Chemistry and Laboratory Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Eriko Watanabe
- Department of Clinical Chemistry and Laboratory Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Takafumi Shimogawa
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Nobutaka Mukae
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Chizuru Ikeda
- Department of Pediatrics, National Hospital Organization Kumamoto Saishun Medical Center, Kumamoto, Japan
| | - Masahiro Migita
- Department of Pediatrics, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Osamu Watanabe
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Yuhki Koga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Perinatal and Pediatric Medicine, Kyushu University, Fukuoka, Japan
| | - Yasunari Sakai
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Shouichi Ohga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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15
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Blanke EN, Holmes GM, Besecker EM. Altered physiology of gastrointestinal vagal afferents following neurotrauma. Neural Regen Res 2021; 16:254-263. [PMID: 32859772 PMCID: PMC7896240 DOI: 10.4103/1673-5374.290883] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The adaptability of the central nervous system has been revealed in several model systems. Of particular interest to central nervous system-injured individuals is the ability for neural components to be modified for regain of function. In both types of neurotrauma, traumatic brain injury and spinal cord injury, the primary parasympathetic control to the gastrointestinal tract, the vagus nerve, remains anatomically intact. However, individuals with traumatic brain injury or spinal cord injury are highly susceptible to gastrointestinal dysfunctions. Such gastrointestinal dysfunctions attribute to higher morbidity and mortality following traumatic brain injury and spinal cord injury. While the vagal efferent output remains capable of eliciting motor responses following injury, evidence suggests impairment of the vagal afferents. Since sensory input drives motor output, this review will discuss the normal and altered anatomy and physiology of the gastrointestinal vagal afferents to better understand the contributions of vagal afferent plasticity following neurotrauma.
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Affiliation(s)
- Emily N Blanke
- Department of Neural and Behavioral Sciences, Penn State University College of Medicine, Hershey, PA, USA
| | - Gregory M Holmes
- Department of Neural and Behavioral Sciences, Penn State University College of Medicine, Hershey, PA, USA
| | - Emily M Besecker
- Department of Health Sciences, Gettysburg College, Gettysburg, PA, USA
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Silva MJ, Antunes N. The utility of heart rate variability as a prognostic factor in children with traumatic brain injury. Brain Inj 2020; 34:1693-1700. [PMID: 33190529 DOI: 10.1080/02699052.2020.1836401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Marta João Silva
- Pediatric Intensive Care Unit, Centro Hospitalar Universitário São João , Porto, Portugal.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine, University of Porto , Porto, Portugal
| | - Natália Antunes
- Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine, University of Porto , Porto, Portugal
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17
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Singh J, Lanzarini E, Santosh P. Organic features of autonomic dysregulation in paediatric brain injury - Clinical and research implications for the management of patients with Rett syndrome. Neurosci Biobehav Rev 2020; 118:809-827. [PMID: 32861739 DOI: 10.1016/j.neubiorev.2020.08.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 08/11/2020] [Accepted: 08/15/2020] [Indexed: 12/18/2022]
Abstract
Rett Syndrome (RTT) is a complex neurodevelopmental disorder with autonomic nervous system dysfunction. The understanding of this autonomic dysregulation remains incomplete and treatment recommendations are lacking. By searching literature regarding childhood brain injury, we wanted to see whether understanding autonomic dysregulation following childhood brain injury as a prototype can help us better understand the autonomic dysregulation in RTT. Thirty-one (31) articles were identified and following thematic analysis the three main themes that emerged were (A) Recognition of Autonomic Dysregulation, (B) Possible Mechanisms & Assessment of Autonomic Dysregulation and (C) Treatment of Autonomic Dysregulation. We conclude that in patients with RTT (I) anatomically, thalamic and hypothalamic function should be explored, (II) sensory issues and medication induced side effects that can worsen autonomic function should be considered, and (III) diaphoresis and dystonia ought to be better managed. Our synthesis of data from autonomic dysregulation in paediatric brain injury has led to increased knowledge and a better understanding of its underpinnings, leading to the development of application protocols in children with RTT.
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Affiliation(s)
- Jatinder Singh
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Centre for Interventional Paediatric Psychopharmacology and Rare Diseases, South London and Maudsley NHS Foundation Trust, London, UK; Centre for Personalised Medicine in Rett Syndrome, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | - Evamaria Lanzarini
- Child and Adolescent Neuropsychiatry Unit, Infermi Hospital, Rimini, Italy
| | - Paramala Santosh
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Centre for Interventional Paediatric Psychopharmacology and Rare Diseases, South London and Maudsley NHS Foundation Trust, London, UK; Centre for Personalised Medicine in Rett Syndrome, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
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18
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Krishnan Y, Smitha B, Cholayil S. Paroxysmal Sympathetic Hyperactivity – An Under-Recognized Entity in Pediatric Brain Tumors: Case Report and Review of Literature. Indian J Med Paediatr Oncol 2020. [DOI: 10.4103/ijmpo.ijmpo_93_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
AbstractParoxysmal sympathetic hyperactivity (PSH) is not a well-recognized syndrome in pediatric brain tumors, but has been described in adults with traumatic brain injury. We describe the case of a child with medulloblastoma presenting with PSH. An index of suspicion is important in early diagnosis of PSH and this ultimately has an impact on the long-term outcome of patients with the syndrome.
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Affiliation(s)
- Yamini Krishnan
- Department of Paediatric Oncology, MVR Cancer Centre and Research Institute, Kozhikode (Calicut), Kerala, India
| | - B Smitha
- Department of Paediatric Oncology, MVR Cancer Centre and Research Institute, Kozhikode (Calicut), Kerala, India
| | - Shamsudheen Cholayil
- Department of Radiation Oncology, MVR Cancer Centre and Research Institute, Kozhikode (Calicut), Kerala, India
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19
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Zheng RZ, Lei ZQ, Yang RZ, Huang GH, Zhang GM. Identification and Management of Paroxysmal Sympathetic Hyperactivity After Traumatic Brain Injury. Front Neurol 2020; 11:81. [PMID: 32161563 PMCID: PMC7052349 DOI: 10.3389/fneur.2020.00081] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 01/22/2020] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Rui-Zhe Zheng
- Department of Anesthesiology, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhong-Qi Lei
- Department of Neurosurgery, The 901th Hospital of the Joint Logistics Support Force of PLA, Anhui, China
| | - Run-Ze Yang
- Department of Clinic of Spine Center, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Guo-Hui Huang
- Department of Otolaryngology-Head and Neck Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Guang-Ming Zhang
- Department of Anesthesiology, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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20
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Branstetter JW, Ohman KL, Johnson DW, Gilbert BW. Management of Paroxysmal Sympathetic Hyperactivity with Dexmedetomidine and Propranolol Following Traumatic Brain Injury in a Pediatric Patient. J Pediatr Intensive Care 2019; 9:64-69. [PMID: 31984161 DOI: 10.1055/s-0039-1698758] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 09/02/2019] [Indexed: 12/29/2022] Open
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.
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Affiliation(s)
- Joshua W Branstetter
- Department of Pharmacy, UF Health Jacksonville, Jacksonville, Florida, United States.,University of Florida College of Pharmacy, Jacksonville, Florida, United States
| | - Kelsey L Ohman
- Department of Pharmacy, UF Health Jacksonville, Jacksonville, Florida, United States.,University of Florida College of Pharmacy, Jacksonville, Florida, United States
| | - Donald W Johnson
- Department of Pharmacy, UF Health Jacksonville, Jacksonville, Florida, United States.,University of Florida College of Pharmacy, Jacksonville, Florida, United States
| | - Brian W Gilbert
- Department of Pharmacy, Wesley Medical Center, Wichita, Kansas, United States
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21
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Weil ZM, Karelina K. Lifelong consequences of brain injuries during development: From risk to resilience. Front Neuroendocrinol 2019; 55:100793. [PMID: 31560884 PMCID: PMC6905510 DOI: 10.1016/j.yfrne.2019.100793] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 08/23/2019] [Accepted: 09/23/2019] [Indexed: 10/26/2022]
Abstract
Traumatic brain injuries in children represent a major public health issue and even relatively mild injuries can have lifelong consequences. However, the outcomes from these injuries are highly heterogeneous, with most individuals recovering fully, but a substantial subset experiencing prolonged or permanent disabilities across a number of domains. Moreover, brain injuries predispose individuals to other kinds of neuropsychiatric and somatic illnesses. Critically, the severity of the injury only partially predicts subsequent outcomes, thus other factors must be involved. In this review, we discuss the psychological, social, neuroendocrine, and autonomic processes that are disrupted following traumatic brain injury during development, and consider the mechanisms the mediate risk or resilience after traumatic brain injury in this vulnerable population.
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Affiliation(s)
- Zachary M Weil
- Department of Neuroscience, Group in Behavioral Neuroendocrinology, Center for Brain and Spinal Cord Repair, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA.
| | - Kate Karelina
- Department of Neuroscience, Group in Behavioral Neuroendocrinology, Center for Brain and Spinal Cord Repair, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
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22
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Lucca LF, Pignolo L, Leto E, Ursino M, Rogano S, Cerasa A. Paroxysmal Sympathetic Hyperactivity Rate in Vegetative or Minimally Conscious State after Acquired Brain Injury Evaluated by Paroxysmal Sympathetic Hyperactivity Assessment Measure. J Neurotrauma 2019; 36:2430-2434. [DOI: 10.1089/neu.2018.5963] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Loris Pignolo
- S. Anna Institute and RAN–Research in Advanced Neurorehabilitation, Crotone, Italy
| | - Elio Leto
- S. Anna Institute and RAN–Research in Advanced Neurorehabilitation, Crotone, Italy
| | - Maria Ursino
- S. Anna Institute and RAN–Research in Advanced Neurorehabilitation, Crotone, Italy
| | - Stefania Rogano
- S. Anna Institute and RAN–Research in Advanced Neurorehabilitation, Crotone, Italy
| | - Antonio Cerasa
- S. Anna Institute and RAN–Research in Advanced Neurorehabilitation, Crotone, Italy
- Neuroimaging Unit, IBFM-CNR, Catanzaro, Italy
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23
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Paroxysmal Sympathetic Hyperactivity After Severe Traumatic Brain Injury in Children: Prevalence, Risk Factors, and Outcome. Pediatr Crit Care Med 2019; 20:252-258. [PMID: 30489486 DOI: 10.1097/pcc.0000000000001811] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe paroxysmal sympathetic hyperactivity in pediatric patients with severe traumatic brain injury using the new consensus definition, the risk factors associated with developing paroxysmal sympathetic hyperactivity, and the outcomes associated with paroxysmal sympathetic hyperactivity. DESIGN Retrospective cohort study. SETTING Academic children's hospital PICU. PATIENTS All pediatric patients more than 1 month and less than 18 years old with severe traumatic brain injury between 2000 and 2016. We excluded patients if they had a history of five possible confounders for paroxysmal sympathetic hyperactivity diagnosis or if they died within 24 hours of admission for traumatic brain injury. MEASUREMENTS AND MAIN RESULTS Our primary outcome was PICU mortality. One hundred seventy-nine patients met inclusion criteria. Thirty-six patients (20%) had at least eight criteria and therefore met classification of "likelihood of paroxysmal sympathetic hyperactivity." Older age was the only factor independently associated with developing paroxysmal sympathetic hyperactivity (odds ratio, 1.08; 95% CI, 1.00-1.16). PICU mortality was significantly lower for those with paroxysmal sympathetic hyperactivity compared with those without paroxysmal sympathetic hyperactivity (odds ratio, 0.08; 95% CI, 0.01-0.52), but PICU length of stay was greater in those with paroxysmal sympathetic hyperactivity (odds ratio, 4.36; 95% CI, 2.94-5.78), and discharge to an acute care or rehabilitation setting versus home was higher in those with paroxysmal sympathetic hyperactivity (odds ratio, 5.59; 95% CI, 1.26-24.84; odds ratio, 5.39; 95% CI, 1.87-15.57, respectively). When paroxysmal sympathetic hyperactivity was diagnosed in the first week of admission, it was not associated with discharge disposition. CONCLUSIONS Our study suggests that the rate of paroxysmal sympathetic hyperactivity in patients with severe traumatic brain injury is higher than previously reported. Older age was associated with an increased risk for developing paroxysmal sympathetic hyperactivity, but severity of the trauma and the brain injury were not. For survivors of severe traumatic brain injury beyond 24 hours who developed paroxysmal sympathetic hyperactivity, there was a lower PICU mortality but also greater PICU length of stay and a lower likelihood of discharge home from the admitting hospital, suggesting that functional outcome in survivors with paroxysmal sympathetic hyperactivity is worse than survivors without paroxysmal sympathetic hyperactivity.
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24
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Abstract
PURPOSE OF REVIEW All critical care is directed at maintaining brain health, but recognizing neurologic complications of critical illness in children is difficult, and limited data exist to guide practice. This article discusses an approach to the recognition and management of seizures, stroke, and cardiac arrest as complications of other critical illnesses in the pediatric intensive care unit. RECENT FINDINGS Convulsive and nonconvulsive seizures occur frequently in children after cardiac arrest or traumatic brain injury and during extracorporeal membrane oxygenation. Seizures may add to neurologic morbidity, and continuous EEG monitoring is needed for up to 24 hours for detection. Hypothermia has not been shown to improve outcome after cardiac arrest in children, but targeted temperature management with controlled normothermia and prevention of fever is a mainstay of neuroprotection. SUMMARY Much of brain-directed pediatric critical care is empiric. Recognition of neurologic complications of critical illness requires multidisciplinary care, serial neurologic examinations, and an appreciation for the multiple risk factors for neurologic injury present in most patients in the pediatric intensive care unit. Through attention to the fundamentals of neuroprotection, including maintaining or restoring cerebral perfusion matched to the metabolic needs of the brain, combined with anticipatory planning, these complications can be prevented or the neurologic injury mitigated.
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25
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Injury of the Hypothalamus in Patients With Hypoxic–Ischemic Brain Injury. Am J Phys Med Rehabil 2018; 97:160-163. [DOI: 10.1097/phm.0000000000000813] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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26
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Letzkus L, Keim-Malpass J, Anderson J, Conaway M, Patrick P, Kennedy C. A retrospective analysis of paroxysmal sympathetic hyperactivity following severe pediatric brain injury. J Pediatr Rehabil Med 2018; 11:153-160. [PMID: 30198878 DOI: 10.3233/prm-160428] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND There are several gaps in the literature related to the prognosis and care of children who have experienced a brain injury then develop paroxysmal sympathetic hyperactivity (PSH). OBJECTIVE The objective of the present study was to explore the characteristics and prognosis of children who have experienced severe brain injury and developed PSH. METHODOLOGY A secondary analysis was conducted using an established clinical dataset of children who had experienced severe brain injury and were admitted to an academic children's rehabilitation center (n= 83). RESULTS Those children with PSH had a significantly longer acute care length of stay (p= 0.024) and total length of stay (p= 0.034) compared with those without PSH. There was no significant difference in cognitive and motor function or transition to rehabilitation between those with and those without PSH after controlling for age and etiology of injury. IMPLICATIONS The findings from the present study reveal factors regarding the elusive phenomenon of PSH among children.
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Affiliation(s)
- Lisa Letzkus
- School of Nursing, University of Virginia, Charlottesville, VA, USA.,Children's Hospital, University of Virginia, Charlottesville, VA, USA
| | | | - Joel Anderson
- College of Nursing, University of Tennessee, Knoxville, TN, USA
| | - Mark Conaway
- Public Health Sciences, University of Virginia, VA, USA
| | - Peter Patrick
- Curry School of Education, University of Virginia, VA, USA
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27
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Meyfroidt G, Baguley IJ, Menon DK. Paroxysmal sympathetic hyperactivity: the storm after acute brain injury. Lancet Neurol 2017; 16:721-729. [PMID: 28816118 DOI: 10.1016/s1474-4422(17)30259-4] [Citation(s) in RCA: 156] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 06/28/2017] [Accepted: 07/20/2017] [Indexed: 10/19/2022]
Abstract
A substantial minority of patients who survive an acquired brain injury develop a state of sympathetic hyperactivity that can persist for weeks or months, consisting of periodic episodes of increased heart rate and blood pressure, sweating, hyperthermia, and motor posturing, often in response to external stimuli. The unifying term for the syndrome-paroxysmal sympathetic hyperactivity (PSH)-and clear diagnostic criteria defined by expert consensus were only recently established. PSH has predominantly been described after traumatic brain injury (TBI), in which it is associated with worse outcomes. The pathophysiology of the condition is not completely understood, although most researchers consider it to be a disconnection syndrome with paroxysms driven by a loss of inhibitory control over excitatory autonomic centres. Although therapeutic strategies to alleviate sympathetic outbursts have been proposed, their effects on PSH are inconsistent between patients and their influence on outcome is unknown. Combinations of drugs are frequently used and are chosen on the basis of local custom, rather than on objective evidence. New rigorous tools for diagnosis could allow better characterisation of PSH to enable stratification of patients for future therapeutic trials.
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Affiliation(s)
- Geert Meyfroidt
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | | | - David K Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, UK.
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28
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Simon DW, Aneja RK, Alexander H, Bell MJ, Bayır H, Kochanek PM, Clark RSB. Minocycline Attenuates High Mobility Group Box 1 Translocation, Microglial Activation, and Thalamic Neurodegeneration after Traumatic Brain Injury in Post-Natal Day 17 Rats. J Neurotrauma 2017; 35:130-138. [PMID: 28699371 DOI: 10.1089/neu.2017.5093] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
In response to cell injury, the danger signal high mobility group box-1 (HMGB) is released, activating macrophages by binding pattern recognition receptors. We investigated the role of the anti-inflammatory drug minocycline in attenuating HMGB1 translocation, microglial activation, and neuronal injury in a rat model of pediatric traumatic brain injury (TBI). Post-natal day 17 Sprague-Dawley rats underwent moderate-severe controlled cortical impact (CCI). Animals were randomized to treatment with minocycline (90 mg/kg, intraperitoneally) or vehicle (saline) at 10 min and 20 h after injury. Shams received anesthesia and craniotomy. We analyzed HMGB1 translocation (protein fractionation and Western blotting), microglial activation (Iba-1 immunohistochemistry), neuronal death (Fluoro-Jade-B [FJB] immunofluorescence), and neuronal cell counts (unbiased stereology). Behavioral assessments included motor and Morris-water maze testing. Nuclear to cytosolic translocation of HMGB1 in the injured brain was attenuated in minocycline versus vehicle-treated rats at 24 h (p < 0.001). Treatment with minocycline reduced microglial activation in the ipsilateral cortex, hippocampus, and thalamus (p < 0.05 vs. vehicle, all regions); attenuated neurodegeneration (FJB-positive neurons) at seven days (p < 0.05 vs. vehicle); and increased thalamic neuronal survival at 14 days (naïve 22773 ± 1012 cells/mm3, CCI + vehicle 11753 ± 464, CCI + minocycline 17047 ± 524; p < 0.001). Minocycline-treated rats demonstrated delayed motor recovery early after injury but had no injury effect on Morris-water maze whereas vehicle-treated rats performed worse than sham on the final two days of testing (both p < 0.05 vs. vehicle). Minocycline globally attenuated HMGB1 translocation and microglial activation in injured brain in a pediatric TBI model and afforded selective thalamic neuroprotection. The HMGB1 translocation and thalamic injury may represent novel mechanistic and regional therapeutic targets in pediatric TBI.
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Affiliation(s)
- Dennis W Simon
- 1 Department of Critical Care Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.,2 Department of Pediatrics, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.,7 Department of Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
| | - Rajesh K Aneja
- 1 Department of Critical Care Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.,2 Department of Pediatrics, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
| | - Henry Alexander
- 7 Department of Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
| | - Michael J Bell
- 1 Department of Critical Care Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.,3 Department of Neurological Surgery, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
| | - Hülya Bayır
- 1 Department of Critical Care Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.,5 Department of Environmental and Occupational Health, and the University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
| | - Patrick M Kochanek
- 1 Department of Critical Care Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.,2 Department of Pediatrics, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.,4 Department of Anesthesiology, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.,7 Department of Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
| | - Robert S B Clark
- 1 Department of Critical Care Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.,2 Department of Pediatrics, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.,4 Department of Anesthesiology, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.,6 Department of Clinical and Translational Science Institute, University of Pittsburgh School of Medicine; and the University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.,7 Department of Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
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29
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Ichimiya Y, Kaku N, Sakai Y, Yamashita F, Matsuoka W, Muraoka M, Akamine S, Mizuguchi S, Torio M, Motomura Y, Hirata Y, Ishizaki Y, Sanefuji M, Torisu H, Takada H, Maehara Y, Ohga S. Transient dysautonomia in an acute phase of encephalopathy with biphasic seizures and late reduced diffusion. Brain Dev 2017; 39:621-624. [PMID: 28413125 DOI: 10.1016/j.braindev.2017.03.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 03/02/2017] [Accepted: 03/17/2017] [Indexed: 01/01/2023]
Abstract
Paroxysmal sympathetic hyperactivity (PSH) is a dysautonomic condition that is associated with various types of acquired brain injuries. Traumatic brain lesions have been documented as the leading cause of PSH. However, detailed clinical features of pediatric PSH caused by intrinsic brain lesions remain to be elusive. We present a 3-year-old boy, who had been diagnosed as having cerebral palsy, developmental delay and epilepsy after perinatal hypoxia-induced brain injury. He developed status epilepticus with fever on the third day of respiratory infection. Whereas the seizure was terminated by systemic infusion of midazolam, consciousness remained disturbed for the next 48h. Serial magnetic resonance imaging studies revealed that acute encephalopathy with biphasic seizures and late reduced diffusion (AESD) evolved on 3days after the seizure. Therapeutic hypothermia was immediately introduced, however, the brain lesion extended to the whole subcortical white matters on day 8. The intermittent bilateral dilation of pupils with increased blood pressure and tachycardia were observed until day 12. Real-time monitoring of electroencephalograms ruled out the recurrent attacks of seizures. The abnormal signs of autonomic nervous system gradually ceased and never relapsed after recovery from the hypothermia. PSH or a transient condition of dysautonomia may emerge and persist during the acute phase of AESD.
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Affiliation(s)
- Yuko Ichimiya
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Emergency and Critical Care Center, Kyushu University, Fukuoka, Japan
| | - Noriyuki Kaku
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Emergency and Critical Care Center, Kyushu University, Fukuoka, Japan
| | - Yasunari Sakai
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Fumiya Yamashita
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Wakato Matsuoka
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Emergency and Critical Care Center, Kyushu University, Fukuoka, Japan
| | - Mamoru Muraoka
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Emergency and Critical Care Center, Kyushu University, Fukuoka, Japan
| | - Satoshi Akamine
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Soichi Mizuguchi
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Emergency and Critical Care Center, Kyushu University, Fukuoka, Japan
| | - Michiko Torio
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshitomo Motomura
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Emergency and Critical Care Center, Kyushu University, Fukuoka, Japan
| | - Yuichiro Hirata
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Emergency and Critical Care Center, Kyushu University, Fukuoka, Japan
| | - Yoshito Ishizaki
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masafumi Sanefuji
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroyuki Torisu
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Pediatrics, Fukuoka Dental College Medical and Dental Hospital, Fukuoka, Japan
| | - Hidetoshi Takada
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiko Maehara
- Emergency and Critical Care Center, Kyushu University, Fukuoka, Japan
| | - Shouichi Ohga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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30
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Abstract
Dysautonomia is a potentially life-threatening syndrome seen in many different types of brain injuries. It involves paroxysmal sympathetic hyperactivity and typically includes a constellation of symptoms, including: tachycardia, tachypnea, hyperthermia, hypertension, diaphoresis, hypertonia, and/or decerebrate or decorticate posturing. It is a clinical diagnosis of exclusion. A multimodal treatment approach is necessary including environmental modifications along with pharmacotherapy. Early management can help prevent comorbidities including secondary brain injury while also improving patient outcomes. This discussion serves as an overview of dysautonomia with a focus on management in the pediatric population including an example of a clinical algorithm and a review of the commonly used medications.
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Affiliation(s)
- Justin M Burton
- Division of Pediatric Rehabilitation Medicine, Children's National Health System, Washington, DC
| | - Olga M Morozova
- Division of Pediatric Rehabilitation Medicine, Children's National Health System, Washington, DC
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Batouche DD, Benatta M, Okbani R, Benatta NF. [High blood pressure during the autonomic crises in children in intensive care unit: Etiologic circumstances and modality therapeutic]. Ann Cardiol Angeiol (Paris) 2017; 66:176-180. [PMID: 28684012 DOI: 10.1016/j.ancard.2017.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 06/01/2017] [Indexed: 06/07/2023]
Abstract
UNLABELLED The dysautonomic (DC) or neurovegetative crisis remains an imperfectly known entity; it associates in a paroxysmal manner a reaction of sympathetic hyperreactivity that can lead to the prognosis. Our objective is to specify the etiological circumstances (DC) and their modality of treatment in pediatric intensive care unit. MATERIALS-METHODS Descriptive study on files of children admitted in the intensive care unit of 2010-2015 who presented a DC acquired during their hospitalization. RESULTS In total, 41 patients included with an average age of 56.92 months presented DC. Among the etiological circumstances Guillain-Barré syndrome and head trauma are noted. Observed symptoms occur on average at one week of admission; they are related to the consequences of DC. The manifestations are polymorphic: a systolic hypertension is present in all cases with an average PAS of 141.24±13.48mmHg, an average PAD of 86.80±11.01mmHg, a vasomotor disorder, a hyperthermia are noted. Cerebral anoxia post cardiac arrest in 4 patients preceded the onset of DC. Apart from the etiologic treatment, 39 patients were intubated with mechanical ventilation, sedated with morphinomimetic and benzodiazepine±lioresal (baclofen). Treatment of hypertension resulted in the administration of a central antihypertensive. Evolution is good in addition to 5 deaths related to neurovegetative disorders. CONCLUSION DC is a poorly understood situation in pediatric intensive care unit, and the circumstances of the disease are variable. The diagnosis must be made with careful consideration because the prognosis may be fatal.
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Affiliation(s)
| | - M Benatta
- Faculté de médecine Oran, Oran, Algérie
| | - R Okbani
- Département de psychologie, université d'Oran, Oran, Algérie
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Paroxysmal Sympathetic Hyperactivity in Children: An Exploratory Evaluation of Nursing Interventions. J Pediatr Nurs 2017; 34:e17-e21. [PMID: 28283208 DOI: 10.1016/j.pedn.2017.02.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 02/27/2017] [Accepted: 02/28/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Paroxysmal sympathetic hyperactivity (PSH) produces symptoms of autonomic instability and muscle over-activity; however, the majority of nursing interventions used in clinical practice are anecdotal and not evidenced based. OBJECTIVE The primary objective was to report nursing documentation of PSH events, and to describe the clinical nursing interventions and care provided to children who have suffered a severe brain injury and are exhibiting PSH. The secondary objective was to demonstrate how the Symptom Management Theory (SMT) can serve as a framework for research related to brain injury and PSH. METHODOLOGY The study consisted of a retrospective chart review of nursing progress notes using direct content analysis. The nested sample of ten randomly selected charts was chosen from a larger quantitative study of 83 children who had suffered severe brain injuries with and without PSH. Textual analysis of verbatim nursing progress notes was used to describe nursing interventions that were used and documented for this patient population. RESULTS The priority nursing interventions to manage these symptoms included medication administration, facilitation of family presence, and strategies to target auditory, tactile, and visual stimuli. The sample received different individual interventions for PSH. Additionally, individual subjects demonstrated different patterns of interventions. IMPLICATIONS While tactile interventions were documented most frequently, there was not a uniform approach to interventions. The SMT can be useful to provide a framework that organizes and tests clinical care and management of PSH strategies.
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Paroxysmal Sympathetic Hyperactivity in Pediatric Rehabilitation: Pathological Features and Scheduled Pharmacological Therapies. J Head Trauma Rehabil 2017; 32:117-124. [DOI: 10.1097/htr.0000000000000255] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Letzkus L, Keim-Malpass J, Kennedy C. Paroxysmal sympathetic hyperactivity: Autonomic instability and muscle over-activity following severe brain injury. Brain Inj 2016; 30:1181-5. [PMID: 27386736 DOI: 10.1080/02699052.2016.1184757] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Children who suffer from moderate-to-severe brain injury can develop a complicating phenomenon known as paroxysmal sympathetic hyperactivity (PSH), characterized by autonomic instability and identified clinically as a cluster of symptoms that can include recurrent fever without a source of infection, hypertension, tachycardia, tachypnea, agitation, diaphoresis and dystonia. Studies with adults have demonstrated that this cluster of symptoms is associated with poorer clinical outcomes (prolonged hospitalizations, poorer cognitive and motor function). However, there have been limited studies in children with PSH. OBJECTIVE To present a literature review regarding PSH following severe brain injury and highlight research needs in children with PSH. METHODOLOGY Electronic databases (CINAHL, Ovid Medline, Web of Science and Google Scholar) were searched. RESULTS Thirty-one research articles met the criteria for inclusion. Several themes emerged regarding the phenomenon of interest during the review: nomenclature, symptoms, management and differences between children and adults. IMPLICATIONS The majority of the research regarding PSH following severe brain injury has been descriptive in nature. Few studies, however, have explored PSH in children with brain injury; therefore, little is known about whether the outcomes of children with PSH are different and, if so, in what ways.
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Affiliation(s)
- Lisa Letzkus
- a University of Virginia School of Nursing.,b University of Virginia Children's Hospital , Charlottesville , VA , USA
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Mrkobrada S, Wei XC, Gnanakumar V. Magnetic resonance imaging findings of bilateral thalamic involvement in severe paroxysmal sympathetic hyperactivity: a pediatric case series. Childs Nerv Syst 2016; 32:1299-303. [PMID: 26463401 DOI: 10.1007/s00381-015-2931-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 10/06/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Paroxysmal sympathetic hyperactivity is a complication of brain injury that has mainly been described in the adult brain injury literature. METHODS We present a case series of three pediatric patients that developed paroxysmal sympathetic hyperactivity of varying severity following hypoxic brain injury. RESULTS Comparison of brain magnetic resonance imaging revealed bilateral and symmetric global ischemic changes in all three cases. However, the thalamus was not affected in the patient with the mild case of paroxysmal sympathetic hyperactivity. In contrast, bilateral and symmetric damage to the thalamus was observed in the two severe cases. CONCLUSIONS Our case series suggests that in hypoxic brain injury, evidence of bilateral ischemic injury to the thalamus on magnetic resonance imaging may be an important early predictor of severity and length of paroxysmal sympathetic hyperactivity. While this is an interesting observation, definite proof of our hypothesis requires further research including analysis of larger numbers of patients and comparison of MRI findings in children with hypoxic brain injury that do not develop paroxysmal sympathetic hyperactivity.
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Affiliation(s)
- Serge Mrkobrada
- Alberta Children's Hospital, Calgary, Canada.
- University of Calgary, Calgary, Canada.
| | - Xing-Chang Wei
- Alberta Children's Hospital, Calgary, Canada
- University of Calgary, Calgary, Canada
| | - Vithya Gnanakumar
- Alberta Children's Hospital, Calgary, Canada
- University of Calgary, Calgary, Canada
- Foothills Medical Centre, Calgary, Canada
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Deepika A, Mathew MJ, Kumar SA, Devi BI, Shukla D. Paroxysmal sympathetic hyperactivity in pediatric traumatic brain injury: A case series of four patients. Auton Neurosci 2015; 193:149-51. [PMID: 26277041 DOI: 10.1016/j.autneu.2015.08.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 07/30/2015] [Accepted: 08/03/2015] [Indexed: 12/18/2022]
Abstract
Paroxysmal sympathetic hyperactivity (PSH) is a condition in which there is extreme autonomic dysregulation leading to multiple episodes of sympathetic hyperactivity. Its occurrence after traumatic brain injury (TBI) in pediatric population is a neglected scenario. In our series, all pediatric patients with moderate and severe head injuries were studied and those patients who developed PSH were monitored for the PSH episodes. Four children out of 36 cases of pediatric severe traumatic brain injury developed features of PSH. Admission GCS of 3 children were 4/15 and 1 child was 6/15 and each of them had an ICU stay of more than 2 weeks and a poor DRS score at discharge. The presence of PSH is known to produce poorer outcome in terms of overall mortality, time needed for recovery, chances of developing infections, etc. which was also seen in these cases presented here. Though some studies have provided guidelines for the management of PSH like symptomatic management and use of drugs like clonidine, bromocriptine, benzodiazepines, and gabapentin, strict management guidelines are not established and exact incidence in pediatric population is not determined.
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Affiliation(s)
- Akhil Deepika
- Department of Clinical Neurosciences, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru 560029, India
| | - Manish Joseph Mathew
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru 560029, India
| | - S Arun Kumar
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru 560029, India
| | - Bhagavatula Indira Devi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru 560029, India
| | - Dhaval Shukla
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru 560029, India.
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Popernack ML, Gray N, Reuter-Rice K. Moderate-to-Severe Traumatic Brain Injury in Children: Complications and Rehabilitation Strategies. J Pediatr Health Care 2015; 29:e1-7. [PMID: 25449002 PMCID: PMC4409446 DOI: 10.1016/j.pedhc.2014.09.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 09/17/2014] [Accepted: 09/20/2014] [Indexed: 10/24/2022]
Abstract
Traumatic brain injury (TBI) is the leading cause of death in children in the United States. Each year 37,200 children sustain a severe TBI, with up to 1.3 million life-years potentially adversely affected. Severe pediatric TBI is associated with significant mortality and morbidity. Of the children who survive their injury, more than 50% experience unfavorable outcomes 6 months after the injury. Although TBI-associated death rates decreased between 1997-2007, disabilities for TBI survivors continue to have both a direct and indirect impact on the economic and human integrity of our society. The degree of disability varies with the severity and mechanism of the injury, but a realm of physical and emotional deficits may be evident for years after the injury occurs. This article describes the pathophysiology of moderate to severe TBI, its associated complications, and opportunities to improve patient outcomes through use of acute management and rehabilitation strategies. To address the many challenges for TBI survivors and their families, including significant financial and emotional burdens, a collaborative effort is necessary to help affected children transition seamlessly from acute care through long-term rehabilitation.
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Farias-Moeller R, Carpenter JL, Dean N, Wells EM. Paroxysmal Sympathetic Hyperactivity in Critically Ill Children with Encephalitis and Meningoencephalitis. Neurocrit Care 2015; 23:380-5. [DOI: 10.1007/s12028-015-0124-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Affiliation(s)
- Ian J Baguley
- Westmead Hospital, Rehabilitation Medicine, Wentworthville, NSW University of Sydney, NSW, Australia
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