Highlights from #EAST2014 - Spinal Perfusion Protocol in Question

This study seems to suggest that our practice of maintaining high MAP's after spinal cord injury may not be necessary.

 INCREASED MAP GOALS AND EPISODES OF RELATIVE HYPOTENSION DO NOT AFFECT IN-HOSPITAL FUNCTIONAL OUTCOMES AFTER ACUTE SPINAL CORD INJURY

Niels D. Martin, MD*, Christopher K Kepler, MD, MBA, Muhammed H Zubair, MD, Amirali Sayadipour, MD, Murray J. Cohen, MD*, Michael S. Weinstein, MD, FACS* Thomas Jefferson University

Presenter: Niels D. Martin, MD

Objectives: Acute spinal cord injury (SCI) is often treated with induced hypertension to enhance spinal cord perfusion. The optimal mean arterial pressure (MAP) likely varies from patient to patient. Arbitrary goals are often set, frequently requiring vasopressors to achieve, with no clear evidence supporting this practice. We hypothesize that increased MAP goals and episodes of relative hypotension do not affect hospital outcome.

Methods: All cervical and thoracic SCI patients treated at a level one trauma & regional spinal cord injury center over at 2.5 year period (2006-2009) were retrospectively reviewed. Lowest and average hourly MAP was recorded for the first 72 hours of hospitalization, allowing for quantification of mean MAP and total number of episodic relative hypotensive events. These data were further compared to daily American Spinal Injury Association Motor Score (AMS), which was used to determine severity of SCI and improvement/decline during hospitalization.

Results: There were 148 SCI patients during the study period. 16 were excluded for missing data. 69.7% required vasopressors. When using a MAP of 65mmHg as acceptable, there was no difference in admission or change in AMS during hospitalization for those averaging above or below 65. However, when MAP >85 is used, increasing episodes of relative hypotension correlated with lower admission AMS (<10 episodes, AMS 66.2; >50 episodes, 22.0; p<0.001) and the need for vasopressors (p<0.03) but showed no statistical change in AMS by hospital discharge.

Conclusions: Episodes of relative hypotension are progressively more frequent with more severe SCI as denoted by lower admission AMS. Episodes of hypotension did not affect the change in AMS during the acute hospitalization, regardless of MAP goal level. Arbitrary MAP goals may not be efficacious but further prospective study with long-term follow-up is needed.