50th Annual Regional Anesthesiology and Acute Pain Medicine Meeting

Stellate Ganglion Block as Adjunctive Therapy for Paroxysmal Sympathetic Hyperactivity after Severe Traumatic Brain Injury

Scott Childs, BS1,2; Matthew N. Jaffa, DO3; Aseel Walker, MD2; Pranjali P Kainkaryam, MD2; Alice DiFrancesco, MD2,4; Kevin Finkel, MD2; Mikayla Zedek2; Yasser Al-Baghdadi, MD2

1 Quinnipiac University School of Medicine, North Haven, CT - 2 Integrated Anesthesia Associates, Department of Anesthesiology, Hartford Hospital, Hartford, CT - 3 Division of Neurocritical Care, Department of Neurology, Ayer Neuroscience Institute, Hartford Hospital, Hartford, CT - 4 IAA Fellowship in Regional Anesthesia and Acute Pain Medicine at Bone and Joint Institute, Hartford

Background

•Paroxysmal Sympathetic Hyperactivity (PSH) is characterized by paroxysms of elevated heart rate, blood pressure, respiratory rate, temperature, sweating, and motor (posturing) often following severe traumatic brain injury (TBI) [1].

•PSH has been associated with increased ICU length of stay, ventilator days, and infection rates [1].

•Current available pharmacologic treatments aim to symptomatically minimize the frequency and severity of episodes.

•Stellate ganglion block (SGB) is a safe procedure known to inhibit the sympathetic chain and reduce sympathetic activity.

•This case series explores the use of SGB as a therapeutic adjunct to PSH after TBI.

Methods

•An ultrasound-guided, single shot, right SGB was performed via a lateral para-carotid approach, at the C6 level, injecting 10 ml of short acting 1.5% mepivacaine. A successful block was confirmed by the onset of either ptosis, meiosis, or conjunctival engorgement.

•The purpose of performing these procedures was to evaluate the safety and feasibility of SGB for this new indication within this specific population. The right stellate ganglion has a greater impact on the sinoatrial (SA) node and heart rate; therefore, blocking this side often results in lower heart rates due to sympathetic inhibition. Additionally, a short-acting local anesthetic was selected to prevent a significant and abrupt decrease in heart rate and, consequently, blood pressure.

•SGB was performed in two patients with TBI and probable PSH, as assessed by the PSH Assessment Measure (PSH-AM) [2].

•Frequency and severity of episodes was assessed pre- and post-SGB through electronic chart review and physician/nursing notes using the Clinical Features Scale (CFS) component of PSH-AM. (Tab. 1&2)

•A single episode was defined as presence of ³3 cardinal symptoms of PSH without other identifiable causes.

Case 1

•27 y/o male with intracerebral hemorrhage and Glasgow Coma Scale (GCS) of 3 having ≥1 PSH episodes per day.

•Uncomplicated SGB 15 days after admission.

•No PSH episodes were experienced through post-SGB day 1.

•Patient returned to baseline episode frequency by post-SGB day 2.

•Only one day through post-SGB day 10 had more severe episodes than episodes 1 day pre-SGB, as assessed by CFS scoring.

•On post-SGB day 6, buprenorphine infusion was weaned reportedly due to better control of PSH symptoms.

Case 2

•28 y/o male with hemorrhagic cerebral contusion and GCS of 8 having ≥1 PSH episodes per day.

•Uncomplicated SGB 19 days after admission.

•No PSH episodes were experienced through post-SGB day 5, then one episode was experienced daily until post SGB day 7.

•Majority of 10 days post-SGB were less severe than episodes pre-SGB, as assessed by CFS scoring

•Multiple PSH medications downgrades (e.g. propofol, bromocriptine, propanol) within 10 days post-SGB

Discussion

•Both patients experienced a reduction in the severity of PSH symptom according to CFS scoring and medication management.

•Despite temporary nature of episode relief, these cases suggest SGB to be a safe and feasible adjunctive intervention for managing PSH.

•Further large-scale studies are necessary to evaluate the effectiveness of a single SGB with a longer acting local anesthetic or multiple/continuous SGB procedures for patients with PSH.

References

1.Jafari AA, Shah M, Mirmoeeni S, et al. Paroxysmal sympathetic hyperactivity during traumatic brain injury. Clin Neurol Neurosurg. 2022 Jan;212:107081. doi.org/10.1016/j.clineuro.2021.107081.

2.Van Eijck MM, Sprengers MOP, Oldenbeuving AW, et al. The use of the PSH-AM in patients with diffuse axonal injury and autonomic dysregulation: A cohort study and review. J Crit Care. 2019 Feb;49:110-117. doi.org/10.1016/j.jcrc.2018.10.018

50th Annual Regional Anesthesiology and Acute Pain Medicine Meeting

STELLATE GANGLION BLOCK AS ADJUNCTIVE THERAPY FOR PAROXYSMAL SYMPATHETIC HYPERACTIVITY AFTER SEVERE TRAUMATIC BRAIN INJURY.

Poster Presenter

Authors

Affiliations

Part of Topic