Objectives: Phrenic nerve pacing (PNP) is a method of respiratory support that can replace mechanical ventilation (MV) in high-level cervical spinal cord injury (SCI) patients with diaphragmatic paralysis. Our objective was to evaluate survival and long-term quality of life in patients with external respiratory support by PNP vs volumetric respirator in patients with severe respiratory insufficiency due to a high-level spinal cord injury. Design: This is a retrospective review study of a prospectively collected database for evaluate the survival and a questionnaire for quality of life has been collected face-to-face or by telephone at present. Patients: Cervical SCI patients with permanent respiratory support (PNP or MV). Methods: Long-term evaluation of a cohort of PNP-supported patients. We performed a comparison between these patients and volumetric respirator-supported patients. For survival analysis, we used the Kaplan-Meier method and Cox proportional hazards model. The health-related quality of life (HRQL) was assessed with SF-36 questionnaire, a general HRQL evaluation. Results: One hundred twenty six patients on permanent respiratory support were evaluated during the study period. Of these, 38 were on PNP and 88 were mechanically ventilated. Paced patients were younger and had a longer survival, but in a multivariate analysis adjusted for age using a multiple logistic correlation we found that length of survival was greater for PNP patients. In terms of HRQL, the PNP-supported patients showed better results in terms of social functioning. Conclusions: PNP is a stable and effective method of long-term respiratory support in this type of patients (SCI patients dependent on external respiratory support). In these patients it improves the length of survival and some social issues by quality of life when compared with patients under MV.
We have made a retrospective comparative study of patients with spinal cord injury, nine with a diaphragmatic pacemaker and 13 with mechanical ventilation. Clinical outcome, cost and subjective satisfaction with both modalities have been evaluated. The functional status was the same with both types of treatment. Proper management of an electric wheelchair and optimal phonation were attained, respectively, in 100% and 89% of pacers and in 77% and 77% of mechanically ventilated. The rate of hospital discharge and satisfaction with the treatment were significantly better for pacers. The time devoted to ventilatory assistance and cost were also more favourable in this group.
Acute acalculous cholecystitis (AAC) is a very serious complication which can be found in patients with multiple serious traumatic lesions (`polytrauma'). Very few patients have been reported in the literature with an acute spinal injury and associated AAC. We report seven patients with polytrauma and acute spinal cord injury who developed AAC. All had no complaint of the principal warning symptom: right upper quadrant abdominal pain. All presented with a palpable mass in this site and the laboratory results were compatible with cholestasis. The diagnosis of AAC was con®rmed both by ultrasound and CT scanning. We discuss the possible precipitating factors and the treatment. One hundred and ninety one patients were admitted to the Intensive Care Unit in our Hospital with SCI over a period of 2 years, all of these in the acute stage. AAC was diagnosed in seven patients among them. Our purpose is to call attention to this clinical condition which can complicate the outcome of patients with multiple trauma and acute spinal cord injury. To date AAC in this group of patients has been infrequently described in the available literature.
Three children, aged 6-10 years, in whom cervical cord injury at the CI-C2 level resulted in apnoea had bilateral implantation of diaphragm pacemakers. With periods of gradual conditioning of the diaphragm muscle to low frequency stimulation and slow respiratory rates they adapted to continuous ventilatory support by simultaneous stimulation of both hemidiaphragms without evidence of fatigue, so far for periods of 23-47 months.Continuous support of ventilation by electrical stimulation of the phrenic nerves was first reported in an adult quadriplegic patient with respiratory muscle paralysis by Glenn etal in 1972 Recent laboratory studies to determine the optimal settings for diaphragmatic pacing have shown that continuous bilateral simultaneous pacing is possible without injury to the phrenic nerve or diaphragm muscle if wide pulse interval stimulation of the phrenic nerve at a slow pulse train repetition (respiratory) rate is used.4 This technique has been applied to older children and adult quadriplegic patients with diaphragmatic paralysis and has provided continuous ventilation without evidence of diaphragm fatigue over extended periods.56The present report describes the results in three quadriplegic children with paralysis of the diaphragm who had diaphragm pacemakers implanted and were able to adapt, through gradual conditioning to pacing, to continuous ventilatory support by simultaneous stimulation of both phrenic nerves, which they have had for from 23 to 47 months. Three quadriplegic children, one boy and two girls (patients 1, 2, and 3) aged 10, six and six years respectively, suffered from traumatic lesions of the cervical cord at the level of C1-C2 as a result of motor vehicle accidents. The time between injury and pacemaker implantation was one year in patient I and 10 and nine months respectively in patients 2 and 3. During this time they were mechanically ventilated continuously via a tracheostomy.Preoperative studies consisted of fluoroscopic confirmation of immobility of the diaphragm and determination of viability of the phrenic nerves through transcutaneous stimulation of the phrenic nerves in the neck.7 8 The operative techniques for implantation of the diaphragm pacemaker have been described in detail by Glenn et al.2 The phrenic nerve was exposed through a thoracotomy in the second intercostal space anteriorly. A monopolar electrode was inserted behind the phrenic nerve in the mediastinal portion midway between the base of the heart and the apex of the thoracic cavity, where it was fixed in place with prolene sutures. The radio receiver was implanted subcutaneously through an incision in the anterolateral axillary line at the costal margin in a pocket developed between the costal margin and the inframammary fold. The pocket was about 10cm deep and extended laterally and medially for a distance of some 3-4cm to accommodate the electronic parts (receiver, anode electrode plate and electrode receiver connectors). A receiver electrode assembly was implanted on the right and left side...
This is a study of two children, aged respectively 10 and 6 years, who sustained a spinal cord injury at the Cl C2, causing apnoea. After the bilateral implantation of diaphragm pacemakers and periods of conditioning, they were able to adapt to continuous and simultaneous full-time ventilatory support of both diaphragms without any sign of fatigue, for more than 24 and 11 months, respectively.
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