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Interventions for Hemodynamic Management

The available evidence to date regarding hemodynamic management during the acute phase of SCI has focused on the association of early aggressive support and improved neurological outcomes. No cause and effect relationships have been established.

Table 5. Early Hemodynamic Management during Acute SCI

Author Year

Country

Research Design

Sample Size

MethodsOutcomes
Vale et al., (1997)

USA

Pre-Post

N=64

Population: Gender: males=29, females=6 (cervical SCI), males=25, females=4 (thoracic SCI); Level of injury: cervical (C3-C7), thoracic (T4-T12); Severity of injury: AIS A-D.

Intervention: Prospective assessment of patients treated in the Intensive Care Unit (ICU) with aggressive hemodynamic support (including the use of arterial BP catheters, Swan-Ganz pulmonary artery catheters, intravenous fluids, colloid, vasopressors, and surgery for decompression and stabilization) as necessary to maintain Mean Arterial Pressure (MAP) >85 mmHg.

Outcome Measures: Neurological improvement as per AIS classification.

Chronicity: Patients were studied beginning within 36h of injury. Follow-up examinations were performed for each patient at 6, 12, and 18 mo post injury.

1.     60% of patients with complete cervical SCI and 33% of patients with complete thoracic SCI improved at least 1 ASIA grade at the last follow-up examination.

2.     92% of patients with incomplete cervical SCI and 88% of patients with incomplete thoracic SCI demonstrated improvement in neurological function 1yr post injury.

Levi et al., (1993)

USA

Pre-Post

N=50

Population: Mean age=39.7 yr; Gender: males=88%, females=12%; Level of injury: cervical; Severity of injury: complete (78%), incomplete (22%).

Intervention: Prospective assessment of patients treated in the Intensive Care Unit (ICU) with invasive hemodynamic monitoring and support (including the use of arterial line and Swan-Ganz catheters, fluid replacement, operative stabilization, and dopamine and/or dobutamine) as necessary to maintain Mean Arterial Pressure (MAP) >90 mmHg.

Outcome Measures: Neurological improvement as per modified Frankel classification.

Chronicity: Patients were studied initially within the first week of injury. Follow-up examinations were performed at 6wk following injury.

1.     Neurological function improved by at least one Frankel grade in 20 of 50 (40%) patients.

2.     Neurological function remained the same in 21 of 50 (42%) of patients.

Discussion

Two studies have examined the association of early aggressive hemodynamic management and neurological improvement over time following SCI. In a study by Vale et al. (1997), 64 patients were treated with aggressive hemodynamic support as needed to maintain a MAP above 85 mmHg while in the ICU. Medical management included the use of arterial BP catheters, Swan-Ganz pulmonary artery catheters, intravenous fluids, colloid, and vasopressors. Surgery was also performed for decompression and stabilization. Treatment was initiated early after injury, beginning within 36 hours of sustaining SCI, and follow-up examinations were performed at 6-, 12-, and 18-month intervals. Improvement by at least 1 American Spinal Injury Assessment (ASIA) grade was observed in 60% of patients with complete cervical SCI and 33% of patients with complete thoracic SCI at the time of their last examination. Improvement in neurological function after 1 year following injury was observed in 92% of patients with incomplete cervical SCI and 88% of patients with incomplete thoracic SCI. Interpretation of this outcome must be taken with caution as there is no comparator group and thus, natural recovery could be occurring alongside the effects of hemodynamic support.

A similar study by Levi et al. (1993) examined 50 patients with cervical SCI who went through invasive hemodynamic monitoring and support during their ICU stay, beginning within the first week of injury. The treatment protocol included the use of arterial line and Swan-Ganz catheters, fluid replacement, operative stabilization, and dopamine and/or dobutamine as necessary to maintain a MAP of more than 90 mmHg. At 6 weeks following injury, improvement in neurological function was observed in 40% of patients and remained the same in 42% of patients. These studies need to be interpreted with care because no cause and effect relationship was established, and recovery may have occurred regardless of hemodynamic support.

Conclusion

There is level 4 evidence (from two pre-post studies; Vale et al., 1997; Levi et al., 1993) that aggressive hemodynamic support in acute SCI patients is associated with improved neurological function.

Hemodynamic support during the acute phase post SCI has been associated with improved neurological outcomes but no cause and effect relationship has been established.