Pharmacological Treatment for Paroxysmal Sympathetic Hyperactivity.

BACKGROUND: Paroxysmal sympathetic hyperactivity, which affects up to 10% of all acquired brain injury survivors, is characterized by elevated heart rate, blood pressure, respiratory rate, and temperature; diaphoresis; and increased posturing. Pharmacological agents that have been studied in the management of this disorder include opiates, γ-aminobutyric acid agents, dopaminergic agents, and ß blockers. Although paroxysmal sympathetic hyperactivity is a relatively common complication after acquired brain injury, there is a paucity of recommendations or comparisons of agents for the management of this disorder. OBJECTIVE: To evaluate all relevant literature on pharmacological therapies used to manage patients with paroxysmal sympathetic hyperactivity to help elucidate possible best practices. METHODS: Of the 27 studies evaluated for inclusion, 10 studies received full review: 4 retrospective cohort studies, 5 single case studies, and 1 case series. RESULTS: Monotherapy is usually not effective in the management of paroxysmal sympathetic hyperactivity and multiple agents with different mechanisms of action should be considered. α2-Agonists such as dexmedetomidine may hold some slight clinical efficacy over agents like propofol, and with respect to oral medications, propranolol might convey some slight advantage compared to others. However, with the limited data available, these results must be interpreted with caution. CONCLUSIONS: As the treatment of paroxysmal sympathetic hyperactivity is reactive to symptomatic evolution over time, critical care nurses play a vital role in the monitoring and treatment of these patients. Limited data exist on the management of paroxysmal sympathetic hyperactivity and larger robust data sets are needed to guide decision-making. (Critical Care Nurse. 2020;40[3]:e9-e16).

Diabetes-associated cardiac autonomic neuropathy.

Cardiac autonomic neuropathy (CAN) is an underdiagnosed cardiovascular complication associated with diabetes. NPs are in a pivotal position to screen patients for CAN. As the incidence of diabetes increases in an aging population, NPs can help prevent complications associated with diabetes and CAN.

Paroxysmal Sympathetic Hyperactivity and Environmental Factors: A Pilot Study.

PROBLEM: Paroxysmal sympathetic hyperactivity (PSH) is a complicated phenomenon that presents as autonomic instability and muscle overactivity in individuals who experience severe brain injury. Identifying potential modifiable environmental nociceptive stimuli is necessary for developing interventions that impact clinical outcomes. OBJECTIVE: The aim of this study was to identify physical environmental nociceptive stimuli that could hinder recovery for children who experience PSH after severe brain injury. METHODOLOGY: This study measured quantitative physical characteristics coupled with data from semistructured interviews, with parents and clinical nurses, to explore the elusive PSH phenomenon after severe brain injury in children. RESULTS: Eight subjects were enrolled in the cohort study. Temperature showed a statistically significant association with PSH (P = .02), with lower temperatures associated with an increased chance of PSH. Blankets were also associated with PSH (P = .009), with the use of blankets associated with a greater chance of PSH. Persons, gown, position, head-of-bed elevation, incontinence of urine and stool, light level, and noise level did not point to a statistically significant association with PSH. Six nursing interviews were conducted with 2 guardian interviews. Themes that are emerging from the qualitative interviews included the priorities of strategies to target auditory, tactile, and visual stimuli. CONCLUSION: Paroxysmal sympathetic hyperactivity environmental strategies need to be explored further in subsequent studies. Environmental interventions could complement pharmacological strategies for the management of this elusive phenomenon with the goal of improving outcomes in children who experience severe brain injury and show PSH.

Paroxysmal Sympathetic Hyperactivity in Children: An Exploratory Evaluation of Nursing Interventions.

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.

Harlequin syndrome as a complication of epidural anesthesia.

Harlequin syndrome is a rare neurological condition that results in unilateral facial flushing and sweating. Although the syndrome is generally a benign condition with complete resolution if appropriate treatment is initiated, unilateral facial flushing can be a sign of several serious conditions and should be thoroughly investigated. Sudden onset of facial flushing related to harlequin syndrome developed in a patient who had bilateral lung transplant with postoperative epidural anesthesia for pain control. Differential diagnosis includes neurovascular disease (acute stroke), malignant neoplasm of brain or lung, Horner syndrome, idiopathic hyperhidrosis, and Frey syndrome. Harlequin syndrome is often easily treated by discontinuing the anesthetic or adjusting placement of the epidural catheter.

Neuroblastoma: What the nurse practitioner should know.

PURPOSE: To provide a comprehensive review of the background, diagnosis, and primary care management of neuroblastoma (NBL) and to describe the pathophysiology, signs and symptoms, and diagnostic tests for the patient with NBL. DATA SOURCES: Extensive review of the worldwide scientific literature on the condition, including primary care articles and studies performed. CONCLUSIONS: NBL is one of the most common tumors of childhood and clinical presentation depends on the site of the primary tumor as well as the presence and location of any metastasis. Treatment includes a combination of surgery, chemotherapy, and radiation, as well as the newer immunotherapy. IMPLICATIONS FOR PRACTICE: NBL is often identified in the primary care setting, and it is important to be able to recognize the presentation and correctly manage the disease. The clinical presentation of NBL, the vital facts needed to ensure that this diagnosis will not be overlooked, and follow-up in a primary care setting will be reviewed.

The patient with Parkinson's disease: part I-treating the motor symptoms; part II-treating the nonmotor symptoms.

PURPOSE: This two-part article provides the nurse practitioner (NP) with information on the developments in the pathophysiology and expanded treatment options in the motor and nonmotor symptoms of Parkinson's disease (PD). The discussion provides treatment strategies that may offer improved ability to manage the disabling symptoms of this neurodegenerative disorder. DATA SOURCES: Review of scientific literature from PubMed search for English language articles on PD from 1998 to 2005 and books or chapters in textbooks published on the disease in the same time frame provided the data source for this article. The content reflects our clinical judgments and experience from clinical practice in the Movement Disorder Clinic at Mayo Clinic Arizona. CONCLUSIONS: The high prevalence of the disease and important advances in its management means that the NP needs to have knowledge of the disorder and the combination of multiple treatment options available for both the motor and the nonmotor symptoms. IMPLICATIONS FOR PRACTICE: PD is a progressive neurodegenerative disease affecting 1% of persons over the age of 60 in the United States. As prevalence increases with age, so does the need for early accurate diagnosis and proper treatment of the PD by the clinician. Advances in the treatment for the motor and nonmotor symptoms of PD provide the clinician with increased options to improve the patient's quality of life.

Recognition and treatment of autonomic dysreflexia.

Patients who are admitted to the critical care unit frequently have numerous diagnoses including ones that can interfere with their treatment. One secondary condition with significant impact on nursing care is autonomic dysreflexia. Noxious stimuli in the ICU can precipitate a life-threatening autonomic response that results in hemodynamic and neurologic complications. Critical care nurses and advanced practice nurses are critical in preventing or making an early identification of this complication.

Managing autonomic dysreflexia through the use of clinical practice guidelines.

One of the goals listed in the American Association of Spinal Cord Injury Nurses (AASCIN) strategic plan 1993-1998, is to provide strategic vision to advance professional practice in spinal cord injury (SCI) nursing. In this quest, along with the development of Standards of Spinal Cord Injury Nursing Practice, the AASCIN Clinical Practice Committee is developing Clinical Practice Guidelines to describe a suggested course of action to address specific clinical conditions or needs of individuals with spinal cord injury. The first Clinical Practice Guideline to be completed is Autonomic Dysreflexia (AD) (Kuric & Hixon, 1996). The purpose of this article is to review the pathophysiology of AD and then describe the symptoms, assessment parameters and nursing interventions suggested in the Clinical Practice Guidelines.

Autonomic dysreflexia--don't let it be a surprise.

This article discusses autonomic dysreflexia, which can occur in patients with spinal cord injury. This potentially life-threatening complication can be managed through an understanding of the disorder and its primary causes. The primary cause of this problem is usually a noxious stimuli that precipitates an abnormal response from the autonomic nervous system. Prevention is the primary nursing treatment and includes implementation of a bladder and bowel management program early in the treatment of the patient with spinal cord injury.

Protocols constructed around the nursing process. 3: Autonomic dysreflexia.

Autonomic dysreflexia is a serious problem in patients with spinal cord lesions above the fifth thoracic level. This nursing protocol outlines assessment, diagnosis, and interventions for nurses and physicians and lists appropriate medications.

Autonomic dysreflexia: a nursing challenge in the care of the patient with a spinal cord injury.

Autonomic dysreflexia is an emergency condition resulting in sudden severe hypertension that can occur in spinal cord injury (SCI) patients above the T-5-6 level. This hypertension has its proximate cause in neurologic, not cardiovascular, mechanisms. Knowledge about pathophysiology, possible consequences, and signs and symptoms will assist the nurse in identifying this syndrome, locating and removing causes, controlling symptoms, and preventing morbidity or mortality. A case study is used to illustrate a typical autonomic dysreflexia episode in a hospitalized patient at risk. Prevention of autonomic dysreflexia and patient and professional education are also addressed.