Complications and outcomes of vasopressor usage in acute traumatic central cord syndrome

Abstract

<jats:sec> <jats:title>OBJECT</jats:title> <jats:p>The optimal mean arterial pressure (MAP) for spinal cord perfusion after trauma remains unclear. Although there are published data on MAP goals after spinal cord injury (SCI), the specific blood pressure management for acute traumatic central cord syndrome (ATCCS) and the implications of these interventions have yet to be elucidated. Additionally, the complications of specific vasopressors have not been fully explored in this injury condition.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>The present study is a retrospective cohort analysis of 34 patients with ATCCS who received any vasopressor to maintain blood pressure above predetermined MAP goals at a single Level 1 trauma center. The collected variables were American Spinal Injury Association (ASIA) grades at admission and discharge, administered vasopressor and associated complications, other interventions and complications, and timing of surgery. The relationship between the 2 most common vasopressors—dopamine and phenylephrine—and complications within the cohort as a whole were explored, and again after stratification by age.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>The mean age of the ATCCS patients was 62 years. Dopamine was the most commonly used primary vasopressor (91% of patients), followed by phenylephrine (65%). Vasopressors were administered to maintain MAP goals fora mean of 101 hours. Neurological status improved by a median of 1 ASIA grade in all patients, regardless of the choice of vasopressor. Sixty-four percent of surgical patients underwent decompression within 24 hours. There was no observed relationship between the timing of surgical intervention and the complication rate. Cardiogenic complications associated with vasopressor usage were notable in 68% of patients who received dopamine and 46% of patients who received phenylephrine. These differences were not statistically significant (OR with dopamine 2.50 [95% CI 0.82–7.78], p = 0.105). However, in the subgroup of patients &gt; 55 years, dopamine produced statistically significant increases in the complication rates when compared with phenylephrine (83% vs 50% for dopamine and phenylephrine, respectively; OR with dopamine 5.0 [95% CI 0.99–25.34], p = 0.044).</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>Vasopressor usage in ATCCS patients is associated with complication rates that are similar to the reported literature for SCI. Dopamine was associated with a higher risk of complications in patients &gt; 55 years. Given the increased incidence of ATCCS in older populations, determination of MAP goals and vasopressor administration should be carefully considered in these patients. While a randomized control trial on this topic may not be practical, a multiinstitutional prospective study for SCI that includes ATCCS patients as a subpopulation would be useful for examining MAP goals in this population.</jats:p></jats:sec>

Continuous Monitoring and Visualization of Optimum Spinal Cord Perfusion Pressure in Patients with Acute Cord Injury

“…Our audit of 42 patients concluded that insertion of the pressure probe and ISP monitoring for up to a week are safe 7 . However, actively increasing SCPP requires vasopressors, which may produce complications such as cardiac dysrhythmias, especially in older patients 22,23 . We previously showed that, after TSCI, the spinal cord swells and is compressed by the dura 24 .…”

Failure of Mean Arterial Pressure Goals to Improve Outcomes Following Penetrating Spinal Cord Injury

“…The results called into question the clinical benefit of applying MAP goals in the population with acute traumatic central cord syndrome. 21 Our series similarly demonstrates high complication rates within the subset of patients with penetrating SCIs. Penetrating injuries are also associated with a poor prognosis because they often result in complete cord transection and, as shown by our series of cases, in hemorrhagic injury.…”

Large armored bridging over fractured vertebra with intraspinal tumor mimicking bony mass caused by migrated fragments of burst cervical vertebra presenting with severe cervical myelopathy

“…These cases may require anterior stabilization, or in addition may need posterior fixation or 360 degree circumferential fusion depending upon degree of spinal instability, clinical feature and progressive neurological deterioration, extent of neural canal compromise, degree of loss of vertebral height, facetal dislocation, rotational component, associated fracture of lamina and associated systemic injury. [8][9][10][11][12] An intensive resuscitation and maintainace of adequate blood pressure under vasopressor support with a mean arterial pressure of 85 mm Hg should be maintained for at least seven days following acute spinal cord injury need to highlighted to improve the neurological outcome,. As in resource starved centres, inadequate infrastructure not only delay in referral to hospital and many of these cases does not get adequate treatment and monitoring in the intensive care unit.…”

“…[10] Readdy et al conclude after analysis of 34 cases with acute traumatic central cord syndrome, who were administered vasopressor agents to maintain targeted mean arterial pressure, definitely led to improvement in neurological status in all the treated patients. [11] Catapano et al highlighted an important social issue and tried to explore the widely prevalent biased attitude of physician as well as paramedical staff towards spinal cord injury victims, especially those with complete neurological deficit while providing resuscitation or inside the hospital care and called for immediate and radical social change on humanitarian approach . Further, such patient should also be helped to get social inclusion.…”