Stellate Ganglion Block Combined With Subanesthetic Ketamine Versus Dexmedetomidine for the Management of Paroxysmal Sympathetic Hyperactivity (PSH) After Traumatic Brain Injury: A Randomized Trial

Background

With appropriate treatment of paroxysmal sympathetic hyperactivity (PSH) following a traumatic brain injury, there is hope for individuals to overcome storming, regain consciousness, and progress toward successful recovery from the brain injury. The primary goal was to monitor changes in mean arterial blood pressure (MABP) in TBI patients with PSH treated with stellate ganglion block combined with subanesthetic dose ketamine versus dexmedetomidine infusion. The secondary outcomes included monitoring changes in heart rate, respiratory rate, temperature decline, duration of the resolution of paroxysmal hypermyotonia, Glasgow Coma Scale (GCS) grading, intensive care unit (ICU) stay, and the number of patients who did not show improvement.

Methods

This randomized, double‐blind controlled study was conducted on 102 patients with traumatic brain injury experiencing PSH. They were randomly allocated into two groups: the SK group ( n  = 51), where patients received a unilateral stellate ganglion block with 5 mL of bupivacaine 0.5% combined with 0.5 mg/kg/h intravenous subanesthetic ketamine infusion, and the D group ( n  = 51), where patients received a loading dose of 1 μg/kg dexmedetomidine for 10 min and then starting an intravenous infusion at a rate of 1 μg/kg/h.

Results

The D group exhibited a significant earlier decrease in MABP compared to the SK group at 30 min, 1, 2, 4, 8, 16, 24, and 48 h ( p value = 0.0001). Both groups experienced similar reductions in RR at the same time points ( p values ≥ 0.5). The temperature decreased after approximately 10 h from initiating treatment with no significant difference between the two groups. Four patients in the D group and three patients in the SK group did not show significant improvement. In terms of GCS, patients in both groups demonstrated significant improvement in GCS grading (18 [35.3%] Grade I, 29 [56.9%] Grade II, and only 1 [2.0%] and 3 [5.9%] Grades III and IV, respectively, in the D group, and 20 [39.2%] Grade I, 28 [54.9%] Grade II, and only 2 [3.9%] Grade III and 1 [2.0%] Grade IV in the SK group) ( p = 0.0001). Both groups had similar durations of ICU stay ( p = 0.222).

Conclusions

A unilateral stellate ganglion block combined with subanesthetic ketamine improves overall neurological recovery and ICU length of stay in post‐TBI PSH compared to continuous dexmedetomidine. However, dexmedetomidine provides a faster reduction in MABP and offers high practical value due to its noninvasive, intravenous delivery.

Trial Registration: ClinicalTrials.gov identifier: NCT06354673.