All over the MAP: describing pressure variability in acute spinal cord injury

Gee, Cameron M.; Tsang, Angela; Bélanger, Lise; Ritchie, Leanna; Ailon, Tamir; Paquette, Scott; Charest-Morin, Raphaële; Dea, Nicolas; Street, John; Fisher, Charles G.; Dvorak, Marcel F.

doi:10.1038/s41393-022-00802-0

Cited by 7 publications

(6 citation statements)

References 28 publications

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“…The full data extraction table for all 73 included articles is provided on the Open Science Framework. These articles consisted 34 original research articles, 6 , 8 , 9 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 13 conference abstracts, 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 13 literature reviews, 24 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 4 systematic reviews, 5 , 13 , 14 , 15 4 letters to the editor, 76 , 77 , ...…”

Section: Resultsmentioning

confidence: 99%

“…3,4 However, these guidelines are based largely upon retrospective studies or uncontrolled case reports and series 5 and questions remain about not only the effectiveness but the feasibility of adhering to these guidelines in practice. 6,7 Recent evidence has indicated that spinal cord perfusion pressure (SCPP) is more closely related to neurologic recovery than is MAP. 8 SCPP represent the net pressure gradient that drives oxygen delivery to the injured cord and is calculated as the difference between MAP and the pressure within the intrathecal space.…”

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Significance of spinal cord perfusion pressure following spinal cord injury: A systematic scoping review

Gee¹

2022

Journal of Clinical Orthopaedics and Trauma

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Section: Resultsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Significance of spinal cord perfusion pressure following spinal cord injury: A systematic scoping review

Gee¹

2022

Journal of Clinical Orthopaedics and Trauma

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“…Likewise, Gee et al reviewed continuous MAP measurements from 16 patients admitted to an intensive care unit in for the first five days post-injury and found that only 24% of MAP recordings were between 85 and 90 mmHg. 57 They emphasized that maintaining MAP within a 5 mmHg range is actually very challenging in clinical practice and suggested that adherence to a guideline for the same is an ‘almost impossible’ task.…”

Section: Discussionmentioning

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

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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.

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“…Moreover, this MAP target range of 5 mmHg – even if it were the “optimal MAP for the spinal cord” - is almost impossible to maintain, given the variability of blood pressures in acute SCI patients and because such precise control cannot be afforded by conventional vasopressors or inotropes. 13 As maintaining a MAP in the 5 mmHg range between 85 and 90 mmHg is often not feasible, clinicians have adopted their own practices, ostensibly “based on the guidelines,” such as keeping the MAP at or above 85 mmHg (ie no upper limit) 14 or targeting the MAP between 85 and 95 mmHg. 15 Obviously, interpreting the 2013 AANS/CNS guidelines in these manners may not pose any specific harm to patients, but the variations in interpretation do reveal that the previous recommendations were not strictly adhered to, even by centers that are very involved in hemodynamic management research.…”

Section: Introductionmentioning

confidence: 99%

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

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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.

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All over the MAP: describing pressure variability in acute spinal cord injury

Cited by 7 publications

References 28 publications

Significance of spinal cord perfusion pressure following spinal cord injury: A systematic scoping review

Significance of spinal cord perfusion pressure following spinal cord injury: A systematic scoping review

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

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

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