Impact of Mean Arterial Blood Pressure During the First Seven Days Post Spinal Cord Injury

Cohn, Jennifer A.; Wright, Jerry; McKenna, Stephen L.; Bushnik, Tamara

doi:10.1310/sci1503-96

Cited by 17 publications

(13 citation statements)

References 25 publications

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“…Five studies monitored and managed MAP over a 7 day period and reported variable impact on neurologic recovery. 15,[30][31][32]36 In the study by Cohn et al, the percent of time patients spent with a MAP below 65 or 70 mmHg during a 7 day period was inversely correlated with AIS grade improvement. 31 In the study of AIS C patients, Hogg et al did not standardize duration of treatment but did demonstrate that improvement in motor function was more closely related to SCPP during a 7 day period.…”

Section: Defining the Duration Of Map Augmentationmentioning

confidence: 97%

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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Section: Defining the Duration Of Map Augmentationmentioning

confidence: 97%

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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“…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

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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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“…Of the 9 papers that were selected, 9 –17 4 contained only patients with cervical injury. 10,11,13,16 Two papers 12,15 reviewed C- and T-spine injuries. Three papers contained patients with injuries of the C, T, and L spine.…”

Section: Patient Demographics and Study Designmentioning

confidence: 99%

“…American Spinal Injury Association motor score was also used as an outcome measure in 4 of the 9 studies. Cohn et al 10 used ASIA motor index from first postinjury neurological examination and compared it to neurological examination before discharge. The duration of follow-up was from admission to discharge, with an average length of stay of 22 days.…”

Section: Patient Demographics and Study Designmentioning

confidence: 99%

“…Cohn et al 10 performed a retrospective chart review of patients presenting with complete tetraplegia to a single center. Neurological outcomes were examined in patients with relation to their MAP during the first 7 days postinjury; the percentage of time each patient spent at different MAP values was documented and used as the final variable.…”

Section: Patient Demographics and Study Designmentioning

confidence: 99%

See 1 more Smart Citation

The Impact of Mean Arterial Pressure on Functional Outcome Post Trauma-Related Acute Spinal Cord Injury: A Scoping Systematic Review of the Human Literature

Sabit

Zeiler

Berrington

2016

J Intensive Care Med

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Impact of Mean Arterial Blood Pressure During the First Seven Days Post Spinal Cord Injury

Cited by 17 publications

References 25 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

The Impact of Mean Arterial Pressure on Functional Outcome Post Trauma-Related Acute Spinal Cord Injury: A Scoping Systematic Review of the Human Literature

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