Higher Mean Arterial Pressure Values Correlate with Neurologic Improvement in Patients with Initially Complete Spinal Cord Injuries

Catapano, Joshua S; Hawryluk, Gregory; Whetstone, William D.; Saigal, Rajiv; Ferguson, Adam R.; Talbott, Jason F.; Bresnahan, Jacqueline C.; Dhall, Sanjay S.; Pan, Jonathan Z.; Beattie, Michael S.; Manley, Geoffrey T.

doi:10.1016/j.wneu.2016.08.053

Cited by 65 publications

(48 citation statements)

References 35 publications

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“…This analysis is similar to one we recently performed to examine the relationship between mean arterial blood pressure values and outcome from spinal cord injury. 6,12…”

Section: Data Curationmentioning

confidence: 99%

Analysis of high-frequency PbtO2 measures in traumatic brain injury: insights into the treatment threshold

Hirschi

Hawryluk

Nielson

et al. 2019

Journal of Neurosurgery

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OBJECTIVEBrain tissue hypoxia is common after traumatic brain injury (TBI). Technology now exists that can detect brain hypoxia and guide corrective therapy. Current guidelines for the management of severe TBI recommend maintaining partial pressure of brain tissue oxygen (PbtO2) > 15–20 mm Hg; however, uncertainty persists as to the optimal treatment threshold. The object of this study was to better inform the relationship between PbtO2 values and outcome for patients with TBI.METHODSPbtO2 measurements were prospectively and automatically collected every minute from consecutive patients admitted to the San Francisco General Hospital neurological ICU during a 6-year period. Mean PbtO2 values in TBI patients as well as the proportion of PbtO2 values below each of 75 thresholds between 0 mm Hg and 75 mm Hg over various epochs up to 30 days from the time of admission were analyzed. Patient outcomes were determined using the Glasgow Outcome Scale. The authors explored putative treatment thresholds by generating 675 separate receiver operating characteristic curves and 675 generalized linear models to examine each 1–mm Hg threshold for various epochs.RESULTSA total of 1,380,841 PbtO2 values were recorded in 190 TBI patients. A high proportion of PbtO2 measures were below 20 mm Hg irrespective of the examined epoch. Time below treatment thresholds was more strongly associated with outcome than mean PbtO2. A treatment window was suggested: a threshold of 19 mm Hg most robustly distinguished patients by outcome, especially from days 3–5; however, benefit was suggested from maintaining values at least as high as 33 mm Hg.CONCLUSIONSThis analysis of high-frequency physiological data substantially informs the relationship between PbtO2 values and outcome. The results suggest a therapeutic window for PbtO2 in TBI patients along with minimum and preferred PbtO2 treatment thresholds, which may be examined in future studies. Traditional treatment thresholds that have the strongest association with outcome may not be optimal.

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“…This analysis is similar to one we recently performed to examine the relationship between mean arterial blood pressure values and outcome from spinal cord injury. 6,12…”

Section: Data Curationmentioning

confidence: 99%

Analysis of high-frequency PbtO2 measures in traumatic brain injury: insights into the treatment threshold

Hirschi

Hawryluk

Nielson

et al. 2019

Journal of Neurosurgery

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“…20,31 Nine studies were retrospective reviews that collected information on MAP after SCI as well as neurological outcome measures throughout the postinjury period. 6,9,16,17,19,21,27,33 Levi et al 20 performed a prospective study in which the authors described the outcomes of a group of 50 patients who underwent spinal immobilization or fixation as indicated, with their postinjury care at a trauma center between 1990 and 1991. An MAP goal higher than 90 mm Hg was maintained with fluids and dopamine for the 1st week after injury, although some patients required the addition of dobutamine for additional support.…”

Section: Relationship Of Map Goals To Outcomesmentioning

confidence: 99%

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

Saadeh

Smith

Joseph

et al. 2017

Neurosurgical Focus

118

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OBJECTIVESpinal 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.METHODSThis 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.RESULTSEleven 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.CONCLUSIONSThere 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.

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“…More recently, results show that patients with complete SCI may derive greater benefit from MAP augmentation. 14 The timing of intervention, and the duration for which MAP values are below threshold, may additionally influence neurological outcome. Similarly, a systematic review by Sabit et al of the effect of MAP on functional outcome revealed that achieving normotension is the most effective treatment for the patient with SCI.…”

Section: Spinal Cord Perfusion and Vasopressor Supportmentioning

confidence: 99%

Update on critical care for acute spinal cord injury in the setting of polytrauma

Yue

Winkler

Rick

et al. 2017

Neurosurgical Focus

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Traumatic spinal cord injury (SCI) often occurs in patients with concurrent traumatic injuries in other body systems. These patients with polytrauma pose unique challenges to clinicians. The current review evaluates existing guidelines and updates the evidence for prehospital transport, immobilization, initial resuscitation, critical care, hemodynamic stability, diagnostic imaging, surgical techniques, and timing appropriate for the patient with SCI who has multisystem trauma. Initial management should be systematic, with focus on spinal immobilization, timely transport, and optimizing perfusion to the spinal cord. There is general evidence for the maintenance of mean arterial pressure of > 85 mm Hg during immediate and acute care to optimize neurological outcome; however, the selection of vasopressor type and duration should be judicious, with considerations for level of injury and risks of increased cardiogenic complications in the elderly. Level II recommendations exist for early decompression, and additional time points of neurological assessment within the first 24 hours and during acute care are warranted to determine the temporality of benefits attributable to early surgery. Venous thromboembolism prophylaxis using low-molecular-weight heparin is recommended by current guidelines for SCI. For these patients, titration of tidal volumes is important to balance the association of earlier weaning off the ventilator, with its risk of atelectasis, against the risk for lung damage from mechanical overinflation that can occur with prolonged ventilation. Careful evaluation of infection risk is a priority following multisystem trauma for patients with relative immunosuppression or compromise. Although patients with polytrauma may experience longer rehabilitation courses, long-term neurological recovery is generally comparable to that in patients with isolated SCI after controlling for demographics. Bowel and bladder disorders are common following SCI, significantly reduce quality of life, and constitute a focus of targeted therapies. Emerging biomarkers including glial fibrillary acidic protein, S100β, and microRNAs for traumatic SCIs are presented. Systematic management approaches to minimize sources of secondary injury are discussed, and areas requiring further research, implementation, and validation are identified.

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Higher Mean Arterial Pressure Values Correlate with Neurologic Improvement in Patients with Initially Complete Spinal Cord Injuries

Cited by 65 publications

References 35 publications

Analysis of high-frequency PbtO2 measures in traumatic brain injury: insights into the treatment threshold

Analysis of high-frequency PbtO2 measures in traumatic brain injury: insights into the treatment threshold

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

Update on critical care for acute spinal cord injury in the setting of polytrauma

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