Hemodynamic management of acute spinal cord injury
1. Patients
with traumatic aSCI (cervical or thoracic ASIA A-D) and central cord syndrome
2. MAP ≥ 85
mmHg for 5 days
3.
Vasopressor agent:
•
Norepinephrine
(most patients)
•
Dopamine
(pts w bradycardia)
•
Phenylephrine
(more potential for harm in patients with bradycardia or heart failure)
•
Epinephrine/vasopressin
(use in refractory response only)
4. Arterial
line if indicated
Hemodynamic management of acute
spinal cord injury
Statement of Need
Perfusion
& oxygen delivery is integral to prevent worsening of acute spinal cord
injuries (aSCI). Some patients with aSCI
may exhibit hemodynamic instability due to damage to autonomic/sympathetic
innervation pathways. The published
literature is weak in this area, which may result in variations in therapy.
Background
A
mean arterial pressure (MAP) target of 85-90mmHg is suggested by guidelines to
ensure adequate spinal perfusion after aSCI.(1-3)
Proactive hemodynamic management also reduces the risk of fluctuations
in blood pressure, which may be deleterious after aSCI (particularly
hypotension).(4)
Isotonic fluid resuscitation and the use of vasopressors may be needed
to meet the target blood pressure in some individual. Overall, the scientific support for the MAP
target of >85mmHg is weak, consisting of under-powered, retrospective
studies. However, there is some
consistency in these studies in that patients who consistently have a MAP
>85mmHg seem to have better neurologic outcomes.(5-8)
Based on animal and human evidence, the level of evidence would be
characterized as low to very low based on GRADE criteria.(9)
The literature primarily pertains to patients with traumatic injuries,
rather than exacerbations of chronic spinal problems, though some of the same
perfusion concerns may be applicable in these situations.
Recommendations
- Patients with
traumatic aSCI
- Acute
cervical or thoracic
- ASIA A-D
- Patients who exhibit
a MAP < 85mmHg may require fluid management and/or vasopressors for
hemodynamic support
- Isotonic
fluids to ensure euvolemia should be initiated promptly (conditional
recommendation, low level of evidence)
- Vasopressors
may be considered to maintain MAP >85mmHg (conditional recommendation,
low level of evidence)
i.
There is no literature to support a
primary vasopressor of choice
ii.
Norepinephrine is a reasonable option for
most patients with aSCI (conditional recommendation, low level of evidence)
iii.
Dopamine may be necessary in patients with
bradycardia who need more chronotropic support (conditional recommendation, low
level of evidence)
iv.
Phenylephrine is also reasonable to use as
a primary or adjunct agent (conditional recommendation, low level of evidence)
1.
Phenylephrine has more potential for harm
in patients with bradycardia or patients with heart failure
v.
Epinephrine, vasopressin should be used in
situations of refractory response only (conditional recommendation, very low
level of evidence)
- The duration
of MAP targeting has commonly been described as 7 days (not to exceed)
(conditional recommendation, low level of evidence)
- Consider continuous
arterial blood pressure monitoring, particularly in the acute phases of
care (good practice statement)
References
1. Schroeder GD, Vaccaro
AR, Welch WC. Best Practies Guidelines:
Spine Injury: NEUROGENIC SHOCK
AND SYSTEMIC PRESSURE-DIRECTED THERAPY. In: American College of Surgeons; 2022.
p. 46-48.
2. Early
acute management in adults with spinal cord injury: a clinical practice
guideline for health-care professionals. 2008;31(4):403-479.
3. Cozzens
JW, Prall JA, Holly L. The 2012 Guidelines for the Management of Acute Cervical
Spine and Spinal Cord Injury. 2013;72 Suppl 2:2-3.
4. Kong
CY, Hosseini AM, Belanger LM, et al. A prospective evaluation of hemodynamic
management in acute spinal cord injury patients. 2013;51(6):466-471.
5. Weinberg
JA, Farber SH, Kalamchi LD, et al. Mean arterial pressure maintenance following
spinal cord injury: Does meeting the target matter? 2021;90(1):97-106.
6. Vale
FL, Burns J, Jackson AB, et al. Combined medical and surgical treatment after
acute spinal cord injury: results of a prospective pilot study to assess the
merits of aggressive medical resuscitation and blood pressure management.
1997;87(2):239-246.
7. Hawryluk
G, Whetstone W, Saigal R, et al. Mean Arterial Blood Pressure Correlates with
Neurological Recovery after Human Spinal Cord Injury: Analysis of High
Frequency Physiologic Data. 2015;32(24):1958-1967.
8. Levi
L, Wolf A, Belzberg H. Hemodynamic parameters in patients with acute cervical
cord trauma: description, intervention, and prediction of outcome.
1993;33(6):1007-1016; discussion 1016-1007.
9. Andrews
JC, Schunemann HJ, Oxman AD, et al. GRADE guidelines: 15. Going from evidence
to recommendation-determinants of a recommendation's direction and strength.
2013;66(7):726-735.
Posted 9-4-23 Authors: Aaron Cook, PharmD, C Reynolds RN, A Bernard MD
