The impact of blood pressure management after spinal cord injury: a systematic review of the literature

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Spinal cord injury (SCI) results in significant morbidity and mortality. Improving neurological recovery by reducing secondary injury is a major principle in the management of SCI. To minimize secondary injury, blood pressure (BP) augmentation has been advocated. The objective of this study was to review the evidence behind BP management after SCI.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>This systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Using the PubMed database, the authors identified studies that investigated BP management after acute SCI. Information on BP goals, duration of BP management, vasopressor selection, and neurological outcomes were analyzed.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>Eleven studies that met inclusion criteria were identified. Nine studies were retrospective, and 2 were single-cohort prospective investigations. Of the 9 retrospective studies, 7 reported a goal mean arterial pressure (MAP) of higher than 85 mm Hg. For the 2 prospective studies, the MAP goals were higher than 85 mm Hg and higher than 90 mm Hg. The duration of BP management varied from more than 24 hours to 7 days in 6 of the retrospective studies that reported the duration of treatment. In both prospective studies, the duration of treatment was 7 days. In the 2 prospective studies, neurological outcomes were stable to improved with BP management. The retrospective studies, however, were contradictory with regard to the correlation of BP management and outcomes. Dopamine, norepinephrine, and phenylephrine were the agents that were frequently used to augment BP. However, more complications have been associated with dopamine use than with the other vasopressors.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>There are no high-quality data regarding optimal BP goals and duration in the management of acute SCI. Based on the highest level of evidence available from the 2 prospective studies, MAP goals of 85–90 mm Hg for a duration of 5–7 days should be considered. Norepinephrine for cervical and upper thoracic injuries and phenylephrine or norepinephrine for mid- to lower thoracic injuries should be considered.</jats:p></jats:sec>

Exploration of surgical blood pressure management and expected motor recovery in individuals with traumatic spinal cord injury

“…The Congress of Neurological Surgeons (CNS) and the American Association of Neurological Surgeons (AANS) (CNS/AANS) issued updated guidelines in 2013 that recommend maintaining MAP between 85 and 90 mmHg in the first 5−7 days after a traumatic SCI in order to improve cord perfusion [14]. These guidelines were affirmed in a recent meta-analysis by Saadeh et al in 2017 [15]. Although these postinjury MAP goals are widely accepted, there is a paucity of evidence to support this practice [14][15][16].…”

The Safety Profile of Intentional or Iatrogenic Sacrifice of the Artery of Adamkiewciz and Its Vicinity’s Spinal Segmental Arteries: A Systematic Review

“…48 This is akin to the traumatic spinal cord injury literature, where prospective level II studies have found that a MAP aim of more than 85 to 90 mm Hg for 5 to 7 days post injury being beneficial in maintaining or improving lost neurological function. 50…”

Clinical Trials in Traumatic Spinal Cord Injury

“…This includes using IV fluids and vasopressors to improve blood flow to the injured cord. Recent reports have recommended norepinephrine as a first line agent given its lower side effect profile than dopamine [48,49].…”

“…Although recent studies have confirmed these published guidelines [50,51], others have suggested that such an arbitrarily elevated MAP goal may not be efficacious and that maintenance of the recommended sustained systemic hypertension may be associated with risks to the patient [49,52,53].…”