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Salasky VR, Chowdhury SH, Chen LK, Almeida E, Kong X, Armahizer M, Pajoumand M, Schrank GM, Rabinowitz RP, Schwartzbauer G, Hu P, Badjatia N, Podell JE. Overlapping Physiologic Signs of Sepsis and Paroxysmal Sympathetic Hyperactivity After Traumatic Brain Injury: Exploring A Clinical Conundrum. Neurocrit Care 2024; 40:1006-1012. [PMID: 37884690 DOI: 10.1007/s12028-023-01862-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 09/12/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND Paroxysmal sympathetic hyperactivity (PSH) occurs in a subset of patients with traumatic brain injury (TBI) and is associated with worse outcomes. Sepsis is also associated with worse outcomes after TBI and shares several physiologic features with PSH, potentially creating diagnostic confusion and suboptimal management of each. This is the first study to directly investigate the interaction between PSH and infection using robust diagnostic criteria. METHODS We performed a retrospective cohort study of patients with TBI admitted to a level I trauma center intensive care unit with hospital length of stay of at least 2 weeks. From January 2016 to July 2018, 77 patients diagnosed with PSH were 1:1 matched by age and Glasgow Coma Scale to 77 patients without PSH. Trauma infectious diseases subspecialists prospectively documented assessments corroborating diagnoses of infection. Extracted data including incidence, timing, classification, and anatomical source of infections were compared according to PSH diagnosis. We also evaluated daily PSH clinical feature severity scores and systemic inflammatory response syndrome (SIRS) criteria and compared values for patients with and without confirmed infection, stratified by PSH diagnosis. RESULTS During the first 2 weeks of hospitalization, there were no differences in rates of suspected (62%) nor confirmed (48%) infection between patients with PSH and controls. Specific treatments for PSH were initiated on median hospital day 7 and for confirmed infections on median hospital day 8. SIRS criteria could identify infection only in patients who were not diagnosed with PSH. CONCLUSIONS In the presence of brain injury-induced autonomic nervous system dysregulation, the initiation and continuation of antimicrobial therapy is a challenging clinical decision, as standard physiologic markers of sepsis do not distinguish infected from noninfected patients with PSH, and these entities often present around the same time. Clinicians should be aware that PSH is a potential driver of SIRS, and familiarity with its diagnostic criteria as proposed by the PSH assessment measure is important. Management by a multidisciplinary team attentive to these issues may reduce rates of inappropriate antibiotic usage and misdiagnoses.
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Affiliation(s)
- Vanessa Rose Salasky
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Program in Trauma, University of Maryland, School of Medicine, University of Maryland Medical Center, 22 S. Greene Street, G7K19, Baltimore, MD, 21201, USA
| | - Sancharee Hom Chowdhury
- Department of Information Systems, University of Maryland Baltimore County, Baltimore, MD, USA
| | - Lujie Karen Chen
- Department of Information Systems, University of Maryland Baltimore County, Baltimore, MD, USA
| | - Ediel Almeida
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Xiangxiang Kong
- Department of Information Systems, University of Maryland Baltimore County, Baltimore, MD, USA
| | - Michael Armahizer
- University of Maryland School of Pharmacy, University of Maryland Medical Center, Baltimore, MD, USA
| | - Mehrnaz Pajoumand
- University of Maryland School of Pharmacy, University of Maryland Medical Center, Baltimore, MD, USA
| | - Gregory M Schrank
- Division of Infectious Diseases, Department of Medicine, Program in Trauma, University of Maryland School of Medicine, University of Maryland Medical Center, Baltimore, MD, USA
| | - Ronald P Rabinowitz
- Division of Infectious Diseases, Department of Medicine, Program in Trauma, University of Maryland School of Medicine, University of Maryland Medical Center, Baltimore, MD, USA
| | - Gary Schwartzbauer
- Department of Neurosurgery, Program in Trauma, University of Maryland School of Medicine, University of Maryland Medical Center, Baltimore, MD, USA
| | - Peter Hu
- Department of Anesthesiology, Program in Trauma, University of Maryland School of Medicine, University of Maryland Medical Center, Baltimore, MD, USA
| | - Neeraj Badjatia
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Program in Trauma, University of Maryland, School of Medicine, University of Maryland Medical Center, 22 S. Greene Street, G7K19, Baltimore, MD, 21201, USA
| | - Jamie Erin Podell
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Program in Trauma, University of Maryland, School of Medicine, University of Maryland Medical Center, 22 S. Greene Street, G7K19, Baltimore, MD, 21201, USA.
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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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Chen Z, Zhang Y, Wu X, Huang H, Chen W, Su Y. Characteristics and Outcomes of Paroxysmal Sympathetic Hyperactivity in Anti-NMDAR Encephalitis. Front Immunol 2022; 13:858450. [PMID: 35464412 PMCID: PMC9020260 DOI: 10.3389/fimmu.2022.858450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/14/2022] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Zhongyun Chen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yan Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaowen Wu
- Department of Neurology, The Second Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Huijin Huang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Weibi Chen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yingying Su
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
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