Adrenergic surge and hypertensive crisis after weaning from neurosedation in children

Abstract

Pharmacological sedation in brain-injured patient is crucial to preserve intra-cerebral hemodynamic stability. Stopping sedation may be accompanied by a procession of clinical and psychic symptoms called withdrawal syndrome (WS) and secondary to an adrenergic discharge leading to tachycardia and possible relapse. We aimed to describe the incidence of these adrenergic surges and the evolution of the WS. Methods Our retrospective study was carried out from April 2017 to March 2018 in the pediatric intensive care unit department of the 1st November University Hospital (61 patients included). Morphine derivatives and hypnotics (midazolam type) were used for sedation. Adrenergic discharge is defined by systolic-diastolic hypertension\xa0>\xa095th percentile in children, tachycardia, tachypnea, agitation. Parameters sociodemographic status, nature of brain injury, duration of sedation, duration of ventilation, time delay to withdraw sedation, time delay of clinical manifestations after WS. Results Fourteen patients (23%, 9 boys and 5 girls) evidenced a WS, mean age: 60.43 months-old. Children were admitted for isolated serious head injury (n\xa0=\xa04), severe meningitis (n\xa0=\xa02), cerebral aspergillosis (n\xa0=\xa01), postoperative brain tumors (n\xa0=\xa07). The morphine sedation duration was 6\xa0±\xa00.5 days; the duration of sedation with benzodiazepines was 7.1\xa0±\xa01.5 days. After the cessation of sedation, patients were ventilated (n\xa0=\xa010), 2 patients had an intubation probe and 2 had a tracheotomy. The peak of the adrenergic surge was observed 7.5\xa0±\xa02.25\xa0hours after cessation of sedation; the averaged systolic blood pressure was 165\xa0mm Hg and the averaged diastolic blood pressure 107\xa0mm Hg; the heart rate was 105 beats/min. Two patients evidencing a state of extreme agitation requiring reintroduction of benzodiazepines for less than 24\xa0hours. The average duration of hospitalization was 12.8 days\xa0±\xa06.3 days [6–22 days]. One patient died in a context of relapse of intracranial hypertension and perilesional edema. Conclusion Stopping sedation in a brain-damaged patient leads to an adrenergic surge that may be responsible for an extension of hospitalization time in an intensive care unit. The cessation of sedation would be provided by a rigorous withdrawal protocol.