A Hemodynamic Safety Checklist Can Improve Blood Pressure Monitoring in Patients with Acute Spinal Cord Injury

Sewell, Mathew D.; Vachhani, Kathak; Hockings, Jason; Chan, Jonathan; Alrawi, Asif; Williams, Richard

doi:10.1016/j.wneu.2019.04.106

Cited by 3 publications

(10 citation statements)

References 13 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Finally, Sewell et al examined whether the institution of a checklist in the hospital reduced the number of times that MAP was recorded below 80 mmHg or 70 mmHg. 37 While the implementation of this checklist reduced the number of episodes of "relative hypotension," there was no impact on change in AIS grade. Unfortunately, none of these studies reported "causation" but rather the association between "poor recovery" or "lack of recovery" and a certain MAP threshold.…”

Section: Smentioning

confidence: 99%

“…Five studies failed to demonstrate an association between MAP and neurologic recovery. 15,[34][35][36][37] The study by Martin et al accessed electronic records of 105 patients with SCI to compare MAP over the first 3 days to motor score recovery during hospitalization. 34 Based on their results, changes in motor score did not differ between patients who required vasopressors and those who did not or between patients who were "relatively hypotensive" and those who maintained specific MAP goals.…”

Section: Defining the Map Rangementioning

confidence: 99%

Section: Part 1 Map Augmentation Target Rangementioning

confidence: 99%

See 2 more Smart Citations

A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on Hemodynamic Management

Kwon,

Tetreault,

Martin

et al. 2024

Global Spine Journal

View full text Add to dashboard Cite

Study Design Clinical practice guideline development following the GRADE process. Objectives Hemodynamic management is one of the only available treatment options that likely improves neurologic outcomes in patients with acute traumatic spinal cord injury (SCI). Augmenting mean arterial pressure (MAP) aims to improve blood perfusion and oxygen delivery to the injured spinal cord in order to minimize secondary ischemic damage to neural tissue. The objective of this guideline was to update the 2013 AANS/CNS recommendations on the hemodynamic management of patients with acute traumatic SCI, acknowledging that much has been published in this area since its publication. Specifically, we sought to make recommendations on 1. The range of mean arterial pressure (MAP) to be maintained by identifying an upper and lower MAP limit; 2. The duration of such MAP augmentation; and 3. The choice of vasopressor. Additionally, we sought to make a recommendation on spinal cord perfusion pressure (SCPP) targets. Methods A multidisciplinary guideline development group (GDG) was formed that included health care professionals from a wide range of clinical specialities, patient advocates, and individuals living with SCI. The GDG reviewed the 2013 AANS/CNS guidelines and voted on whether each recommendation should be endorsed or updated. A systematic review of the literature, following PRISMA standards and registered in PROSPERO, was conducted to inform the guideline development process and address the following key questions: (i) what are the effects of goal-directed interventions to optimize spinal cord perfusion on extent of neurological recovery and rates of adverse events at any time point of follow-up? and (ii) what are the effects of particular monitoring techniques, perfusion ranges, pharmacological agents, and durations of treatment on extent of neurological recovery and rates of adverse events at any time point of follow-up? The GDG combined the information from this systematic review with their clinical expertise in order to develop recommendations on a MAP target range (specifically an upper and lower limit to target), the optimal duration for MAP augmentation, and the use of vasopressors or inotropes. Using methods outlined by the GRADE working group, recommendations were formulated that considered the balance of benefits and harms, financial impact, acceptability, feasibility and patient preferences. Results The GDG suggested that MAP should be augmented to at least 75-80 mmHg as the “lower limit,” but not actively augmented beyond an “upper limit” of 90-95 mmHg in order to optimize spinal cord perfusion in acute traumatic SCI. The quality of the evidence around the “target MAP” was very low, and thus the strength of this recommendation is weak. For duration of hemodynamic management, the GDG “suggested” that MAP be augmented for a duration of 3-7 days. Again, the quality of the evidence around the duration of MAP support was very low, and thus the strength of this recommendation is also weak. The GDG felt that a recommendation on the choice of vasopressor or the use of SCPP targets was not warranted, given the dearth of available evidence. Conclusion We provide new recommendations for blood pressure management after acute SCI that acknowledge the limitations of the current evidence on the relationship between MAP and neurologic recovery. It was felt that the low quality of existing evidence and uncertainty around the relationship between MAP and neurologic recovery justified a greater range of MAP to target, and for a broader range of days post-injury than recommended in previous guidelines. While important knowledge gaps still remain regarding hemodynamic management, these recommendations represent current perspectives on the role of MAP augmentation for acute SCI.

show abstract

Section: Smentioning

confidence: 99%

Section: Defining the Map Rangementioning

confidence: 99%

See 1 more Smart Citation

A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on Hemodynamic Management

Kwon,

Tetreault,

Martin

et al. 2024

Global Spine Journal

View full text Add to dashboard Cite

show abstract

“…The Effects of MAP Support on Neurological Recovery. This update identified five new studies, 25,26,30,40,44 which were considered in addition to 11 from the prior review. 20,[22][23][24]27,[33][34][35]39,42,43 According to very low quality evidence from 16 observational studies (total n = 1109), the anticipated effect of MAP support on neurological recovery remains uncertain.…”

Section: Effects Of Interventions To Optimize Spinal Cord Perfusionmentioning

confidence: 99%

“…Fifteen studies reported on associations between neurological recovery and MAP goals of 70-95 mmHg. [22][23][24][25][26][27][28]33,35,37,38,40,[42][43][44] VERY LOW Study design, risk of bias, indirectness SCPP goal ranges…”

Section: Map Goal Rangesmentioning

confidence: 99%

Interventions to Optimize Spinal Cord Perfusion in Patients With Acute Traumatic Spinal Cord Injury: An Updated Systematic Review

Evaniew,

Davies,

Farahbakhsh

et al. 2024

Global Spine Journal

View full text Add to dashboard Cite

Study design Systematic review update. Objectives Interventions that aim to optimize spinal cord perfusion are thought to play an important role in minimizing secondary ischemic damage and improving outcomes in patients with acute traumatic spinal cord injuries (SCIs). However, exactly how to optimize spinal cord perfusion and enhance neurologic recovery remains controversial. We performed an update of a recent systematic review (Evaniew et al, J. Neurotrauma 2020) to evaluate the effects of Mean Arterial Pressure (MAP) support or Spinal Cord Perfusion Pressure (SCPP) support on neurological recovery and rates of adverse events among patients with acute traumatic SCI. Methods We searched PubMed/MEDLINE, EMBASE and ClinicalTrials.gov for new published reports. Two reviewers independently screened articles, extracted data, and evaluated risk of bias. We implemented the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach to rate confidence in the quality of the evidence. Results From 569 potentially relevant new citations since 2019, we identified 9 new studies for inclusion, which were combined with 19 studies from a prior review to give a total of 28 studies. According to low or very low quality evidence, the effect of MAP support on neurological recovery is uncertain, and increased SCPP may be associated with improved neurological recovery. Both approaches may involve risks for specific adverse events, but the importance of these adverse events to patients remains unclear. Very low quality evidence failed to yield reliable guidance about particular monitoring techniques, perfusion ranges, pharmacological agents, or durations of treatment. Conclusions This update provides an evidence base to support the development of a new clinical practice guideline for the hemodynamic management of patients with acute traumatic SCI. While avoidance of hypotension and maintenance of spinal cord perfusion are important principles in the management of an acute SCI, the literature does not provide high quality evidence in support of a particular protocol. Further prospective, controlled research studies with objective validated outcome assessments are required to examine interventions to optimize spinal cord perfusion in this setting.

show abstract

Intermittent and Transient Hypotension-related Anterior Cord Syndrome following Elective Cervical Spine Surgery: A Case Report

Greig¹,

Zoller²,

Sheppard³

et al. 2021

JOCR

View full text Add to dashboard Cite

Introduction: Anterior cord syndrome (ACS) is a type of incomplete spinal cord injury caused by either direct compression of the anterior spinal cord, or by ischemia of the anterior spinal artery. This phenomenon has neither been described transiently nor intraoperatively. Case Report: We describe the case of a 61-year-old male who developed intermittent and transient anterior spinal cord syndrome secondary to hypotension related hypoperfusion of the anterior spinal artery after elective cervical spine surgery. Through close blood pressure monitoring and intensive care unit support, the patient regained full neurological recovery. Conclusion: Anterior spinal cord syndrome is a rare condition affecting the anterior 2/3 of the spinal cord, resulting in incomplete paralysis. Blood flow can be disrupted through the anterior spinal artery, either through thrombosis or hypotension. We describe our rare case so that surgeons may recognize this potentially devastating condition. Keywords: Spine, hypoperfusion, hypotension, cord injury, anterior cord syndrome.

show abstract

A Hemodynamic Safety Checklist Can Improve Blood Pressure Monitoring in Patients with Acute Spinal Cord Injury

Cited by 3 publications

References 13 publications

A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on Hemodynamic Management

A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on Hemodynamic Management

Interventions to Optimize Spinal Cord Perfusion in Patients With Acute Traumatic Spinal Cord Injury: An Updated Systematic Review

Intermittent and Transient Hypotension-related Anterior Cord Syndrome following Elective Cervical Spine Surgery: A Case Report

Contact Info

Product

Resources

About