title: Rectal propranolol controls paroxysmal sympathetic hyperactivity: a case report.
abstract: Paroxysmal sympathetic hyperactivity (PSH) affects approximately 10% of survivors of acquired brain injury and is associated with substantial morbidity. The most effective maintenance therapies include oral β-blockers and α-2 antagonists. We report the use of rectal propranolol for symptomatic control of PSH in a critically ill patient with an altered gastrointestinal tract for whom oral intake was contraindicated. A 15-year-old Caucasian male with no past medical history was admitted status post all-terrain vehicle rollover with multiple intra-abdominal injuries. On hospital day 40, the patient experienced cardiac arrest with a subsequent anoxic brain injury, which was complicated by the development of PSH on post-arrest day 1. Because of his altered gastrointestinal tract, he was symptomatically managed with propranolol 40 mg per rectum every 6 hours in the form of specially prepared suppositories, intravenously infused morphine and dexmedetomidine, and a transdermal clonidine patch. The patient improved clinically during this treatment and was transferred to a rehabilitation facility. This is the first case report to describe successful use of propranolol suppositories in a clinical environment. This case supports the use of propranolol suppositories as a potential alternative route when oral administration is not possible.
authors.affiliation: Department of Pharmacy, University of Kentucky HealthCare, Lexington, Kentucky.
authors.forename: Casey C
authors.initials: CC
authors.lastname: May
authors.forename: Douglas R
authors.initials: DR
authors.lastname: Oyler
authors.forename: Sara E
authors.initials: SE
authors.lastname: Parli
authors.forename: Cynthia L
authors.initials: CL
authors.lastname: Talley
mesh_terms: D000007:Abdominal Injuries / Q000188:drug therapy* / Q000503:physiopathology; D000285:Administration, Rectal; D000293:Adolescent; D000319:Adrenergic beta-Antagonists / Q000008:administration & dosage*; D001342:Autonomic Nervous System Diseases / Q000188:drug therapy* / Q000503:physiopathology; D041981:Gastrointestinal Tract / Q000187:drug effects* / Q000293:injuries / Q000503:physiopathology; D006801:Humans; D008297:Male; D011433:Propranolol / Q000008:administration & dosage*; D014949:Wounds, Nonpenetrating / Q000188:drug therapy* / Q000503:physiopathology
chemical_list: D000319:Adrenergic beta-Antagonists; D011433:Propranolol
keywords: paroxysmal sympathetic hyperactivity; pharmacokinetics; rectal propranolol