A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on Hemodynamic Management

• Published in: Global spine journal 2024-03, Vol.14 (3_suppl), p.187S-211S
• Main Authors: Kwon, Brian K., Tetreault, Lindsay A., Martin, Allan R., Arnold, Paul M., Marco, Rex A.W., Newcombe, Virginia F.J., Zipser, Carl M., McKenna, Stephen L., Korupolu, Radha, Neal, Chris J., Saigal, Rajiv, Glass, Nina E., Douglas, Sam, Ganau, Mario, Rahimi-Movaghar, Vafa, Harrop, James S., Aarabi, Bizhan, Wilson, Jefferson R., Evaniew, Nathan, Skelly, Andrea C., Fehlings, Michael G.
• Format: Article
• Language: English
• Subjects: Clinical medicine; Clinical practice guidelines; Hemodynamics; Patients; Special Issue; Spinal cord injuries; Systematic review
• ISSN: 2192-5682; 2192-5690
• DOI: 10.1177/21925682231202348

Study Design Clinical practice guideline development following the GRADE process. Objectives Hemodynamic management is one of the only available treatment options that likely improves neurologic outcomes in patients with acute traumatic spinal cord injury (SCI). Augmenting mean arterial pressure (MAP) aims to improve blood perfusion and oxygen delivery to the injured spinal cord in order to minimize secondary ischemic damage to neural tissue. The objective of this guideline was to update the 2013 AANS/CNS recommendations on the hemodynamic management of patients with acute traumatic SCI, acknowledging that much has been published in this area since its publication. Specifically, we sought to make recommendations on 1. The range of mean arterial pressure (MAP) to be maintained by identifying an upper and lower MAP limit; 2. The duration of such MAP augmentation; and 3. The choice of vasopressor. Additionally, we sought to make a recommendation on spinal cord perfusion pressure (SCPP) targets. Methods A multidisciplinary guideline development group (GDG) was formed that included health care professionals from a wide range of clinical specialities, patient advocates, and individuals living with SCI. The GDG reviewed the 2013 AANS/CNS guidelines and voted on whether each recommendation should be endorsed or updated. A systematic review of the literature, following PRISMA standards and registered in PROSPERO, was conducted to inform the guideline development process and address the following key questions: (i) what are the effects of goal-directed interventions to optimize spinal cord perfusion on extent of neurological recovery and rates of adverse events at any time point of follow-up? and (ii) what are the effects of particular monitoring techniques, perfusion ranges, pharmacological agents, and durations of treatment on extent of neurological recovery and rates of adverse events at any time point of follow-up? The GDG combined the information from this systematic review with their clinical expertise in order to develop recommendations on a MAP target range (specifically an upper and lower limit to target), the optimal duration for MAP augmentation, and the use of vasopressors or inotropes. Using methods outlined by the GRADE working group, recommendations were formulated that considered the balance of benefits and harms, financial impact, acceptability, feasibility and patient preferences. Results The GDG suggested that MAP should be augmented to at least 7