Influence of paroxysmal sympathetic hyperactivity (PSH) on the functional outcome of neurological early rehabilitation patients: a case control study

Abstract

Background Paroxysmal Sympathetic Hyperactivity (PSH) is a frequently observed condition among critically ill patients on intensive care units. According to different studies, PSH is associated with worse recovery and increased mortality in acute-care facilities. In this monocentric, retrospective case-control study, we investigated whether this association also applies to post-acute neurological early rehabilitation. Methods The study included n = 387 patients, admitted to an intensive care or intermediate care unit within 1 year (2016). Among these, 97 patients showed clinical signs of PSH. For each patient with PSH, a patient without PSH was identified, controlling for age, gender, functional and respiratory status upon admission. However, for 25 patients with PSH, there was no suitable control patient fulfilling all defined matching criteria. Primary outcome was type of discharge, dichotomized into favorable (follow-up rehabilitation) and unfavorable outcome (all others). Secondary outcome measures were functional and respiratory status, number of secondary diagnoses, duration of treatment interruptions and length of stay at discharge. Results About 25% of neurological early rehabilitation patients showed clinical signs of PSH. A young age (OR = 0.94; CI = 0.91–0.97) and less severe PSH symptoms (OR = 0.79; CI = 0.69–0.90) were independent predictors of a favorable outcome. In addition, severity of PSH symptoms was associated with weaning duration, while the occurrence of PSH symptoms alone had no influence on most secondary outcome variables. The treatment on intermediate care units proved to be longer for patients with PSH symptoms, only. Conclusions Patients with PSH represent a large group of neurological early rehabilitation patients. Overall, we did not find PSH-related differences in most of the examined outcome measures. However, severe PSH symptoms seem to be associated with poorer outcome and longer treatment on intermediate care units, in order to prevent possible complications.

Paroxysmal Sympathetic Hyperactivity in Severe Anti-N-Methyl-d-Aspartate Receptor Encephalitis: A Single Center Retrospective Observational Study

“…In previous literature about brain injuries, PSH is more common in males (10), younger patients (14-16), and patients with lower GCS scores (4,11). However, no significant risk factors were found in this study, although patients with PSH tended to be younger (P=0.084).…”

“…In EIR model, the absence of descending inhibition results in exaggerated spinal reactivity, with sympathetic efflux triggered by non-nociceptive peripheral stimuli. Recognition of PSH is important, because it's not rare in severe brain injury, associated with increased mortality, higher healthcare costs, longer hospitalizations, and poorer outcomes (3,4).…”

Identification and Management of Paroxysmal Sympathetic Hyperactivity After Traumatic Brain Injury

“…The cause of increased mortality of PSH in severe TBI patients may result from those who did not respond to treatments rather than the complication itself, which leads to a prolonged duration of this complication, resulting in metabolic disorders or malnutrition and the deterioration of neurological condition occurring eventually (10,11). However, a most recent casecontrol study, which was not consistent with regard to the effects of outcomes, revealed that the occurrence of PSH symptoms was not associated with more complications and higher mortality (12). Because of a lack of unified management process of PSH after TBI, between-study differences may ultimately emerge (3).…”

Incidence of Paroxysmal Sympathetic Hyperactivity after Traumatic Brain Injury in a Tertiary Care ICU: A Retrospective Cohort Study

“…In concordance with previous studies, our study too has shown that PSH patients have longer period of stay in hospital. 13,29,30 Mathew et al 31 concluded that the presence of PSH in patients with severe TBI was associated with a prolonged hospital stay, more deaths, and unfavorable outcome. Patients often are more vulnerable to infections and spend longer times on ventilators, which can lead to an increased risk of various lung diseases.…”

“…11,12 However, some studies have found that PSH was not an independent predictor for the increased morbidity or poor clinical outcome. 4,8,13 Several intracranial pathologies, such as seizures, hydrocephalus, and hypoxia, invariably have overlapping manifestations with PSH. Hence, under-recognition and misdiagnosis frequently occur in clinical practice.…”