Medical and Surgical Management after Spinal Cord Injury: Vasopressor Usage, Early Surgerys, and Complications

Inoue, Tomoo; Manley, Geoffrey T.; Patel, Nihari; Whetstone, William D.

doi:10.1089/neu.2013.3061

Cited by 110 publications

(86 citation statements)

References 32 publications

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“…By comparison, Inoue et al reported complications with dopamine or phenylephrine usage such as arrhythmias, acidosis, and skin necrosis. 15 In our laminectomized patients, ISP was significantly higher in the supine than the lateral position by up to 8 mm Hg for cervical injuries and 18 mm Hg for thoracic injuries. This finding has important implications for nursing care: we recommend avoiding wound compression (e.g., by avoiding the supine position or by placing a ring-shaped pillow around the wound).…”

Section: Discussionmentioning

confidence: 56%

“…25 Intervening to elevate the blood pressure without monitoring ISP and SCPP from the injury site is potentially dangerous due to cardiogenic complications. 15 From our experience with ISP/SCPP monitoring, and by analogy with the concept of individualized CPP opt in TBI, it seems that SCPP opt varies between patients, thus suggesting individualized SCPP management rather than setting generalized guidelines. 20 Currently, ICP monitoring and CPP optimization are the standard of care when managing severe TBI patients in developed countries.…”

Section: Discussionmentioning

confidence: 99%

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Safety profile and probe placement accuracy of intraspinal pressure monitoring for traumatic spinal cord injury: Injured Spinal Cord Pressure Evaluation study

Phang

Zoumprouli

Saadoun

et al. 2016

SPI

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OBJECTIVE A novel technique for monitoring intraspinal pressure and spinal cord perfusion pressure in patients with traumatic spinal cord injury was recently described. This is analogous to monitoring intracranial pressure and cerebral perfusion pressure in patients with traumatic brain injury. Because intraspinal pressure monitoring is a new technique, its safety profile and impact on early patient care and long-term outcome after traumatic spinal cord injury are unknown. The object of this study is to review all patients who had intraspinal pressure monitoring to date at the authors' institution in order to define the accuracy of intraspinal pressure probe placement and the safety of the technique. METHODS At the end of surgery to fix spinal fractures, a pressure probe was inserted intradurally to monitor intraspinal pressure at the injury site. Postoperatively, CT scanning was performed within 48 hours and MRI at 2 weeks and 6 months. Neurointensive care management and complications were reviewed. The American Spinal Injury Association Impairment Scale (AIS) grade was determined on admission and at 2 to 4 weeks and 12 to 18 months postoperation. RESULTS To date, 42 patients with severe traumatic spinal cord injuries (AIS Grades A–C) had undergone intraspinal pressure monitoring. Monitoring started within 72 hours of injury and continued for up to a week. Based on postoperative CT and MRI, the probe position was acceptable in all patients, i.e., the probe was located at the site of maximum spinal cord swelling. Complications were probe displacement in 1 of 42 patients (2.4%), CSF leakage that required wound resuturing in 3 of 42 patients (7.1%), and asymptomatic pseudomeningocele that was diagnosed in 8 of 42 patients (19.0%). Pseudomeningocele was diagnosed on MRI and resolved within 6 months in all patients. Based on the MRI and neurological examination results, there were no serious probe-related complications such as meningitis, wound infection, hematoma, wound breakdown, or neurological deterioration. Within 2 weeks postoperatively, 75% of patients were extubated and 25% underwent tracheostomy. Norepinephrine was used to support blood pressure without complications. Overall, the mean intraspinal pressure was around 20 mm Hg, and the mean spinal cord perfusion pressure was around 70 mm Hg. In laminectomized patients, the intraspinal pressure was significantly higher in the supine than lateral position by up to 18 mm Hg after thoracic laminectomy and 8 mm Hg after cervical laminectomy. At 12 to 18 months, 11.4% of patients had improved by 1 AIS grade and 14.3% by at least 2 AIS grades. CONCLUSIONS These data suggest that after traumatic spinal cord injury intradural placement of the pressure probe is accurate and intraspinal pressure monitoring is safe for up to a week. In patients with spinal cord injury who had laminectomy, the supine position should be avoided in order to prevent rises in intraspinal pressure.

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Section: Discussionmentioning

confidence: 56%

Section: Discussionmentioning

confidence: 99%

Safety profile and probe placement accuracy of intraspinal pressure monitoring for traumatic spinal cord injury: Injured Spinal Cord Pressure Evaluation study

Phang

Zoumprouli

Saadoun

et al. 2016

SPI

View full text Add to dashboard Cite

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“…20 In patients with acute traumatic central cord syndrome, high rates of cardiogenic complications are independently associated with dopamine and phenylephrine, and more serious complications were associated with dopamine use in elderly patients. 42 Higher complication rates have been reported when vasopressors were used contrary to guidelines: e.g., use of dopamine for injuries below T-6. 76 Interestingly, in a small study of 11 patients, norepinephrine was found to increase cord perfusion pressure by 2 mm Hg compared with dopamine, 2 which may be of clinical advantage in maintaining strict MAP goals during acute care.…”

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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“…Our findings thus challenge current guidelines, which recommend maintaining mean arterial pressure at 85 -90 mmHg for a week after TSCI 28 . Elevating mean arterial pressure after TSCI requires inotropic support, which is associated with several complications 29 . To reduce inotrope requirements and, therefore, inotrope-related complications when aiming for SCPP 90 -100 mmHg, expansion duroplasty could be performed to lower the ISP 8 .…”

Section: Annals Of Neurologymentioning

confidence: 99%

Microdialysis to Optimize Cord Perfusion and Drug Delivery in Spinal Cord Injury

Phang

Zoumprouli

Papadopoulos

et al. 2016

Annals of Neurology

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OBJECTIVE:There is lack of monitoring from the injury site to guide management of patients with acute traumatic spinal cord injury. Here we describe a bedside microdialysis monitoring technique for optimizing spinal cord perfusion and drug delivery at the injury site.METHODS: 14 patients were recruited within 72 hours of severe spinal cord injury. We inserted intradurally at the injury site a pressure probe, to monitor continuously spinal cord perfusion pressure, and a microdialysis catheter, to monitor hourly glycerol, glutamate, glucose, lactate and pyruvate. The pressure probe and microdialysis catheter were placed on the surface of the injured cord. RESULTS:Microdialysis monitoring did not cause serious complications. Spinal cord perfusion pressure 90 -100 mmHg and tissue glucose >4.5 mM minimized metabolic derangement at the injury site. Increasing spinal cord perfusion pressure by ~10 mmHg, increased the entry of intravenously administered dexamethasone at the injury site three-fold. INTERPRETATION:This study determined the optimum spinal cord perfusion pressure and optimum tissue glucose concentration at the injury site. We also identified spinal cord perfusion pressure as a key determinant of drug entry into the injured spinal cord. Our findings challenge current guidelines, which recommend maintaining mean arterial pressure at 85 -90 mmHg for a week after spinal cord injury. We propose that future drug trials for spinal cord injury include pressure and microdialysis monitoring to optimize spinal cord perfusion and maximize drug delivery at the injury site.

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Medical and Surgical Management after Spinal Cord Injury: Vasopressor Usage, Early Surgerys, and Complications

Cited by 110 publications

References 32 publications

Safety profile and probe placement accuracy of intraspinal pressure monitoring for traumatic spinal cord injury: Injured Spinal Cord Pressure Evaluation study

Safety profile and probe placement accuracy of intraspinal pressure monitoring for traumatic spinal cord injury: Injured Spinal Cord Pressure Evaluation study

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

Microdialysis to Optimize Cord Perfusion and Drug Delivery in Spinal Cord Injury

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