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

Global Spine Journal, 2024 · DOI: 10.1177/21925682231202348 · Published: March 1, 2024

Spinal Cord Injury Cardiovascular Science Research Methodology & Design

Simple Explanation

This clinical practice guideline focuses on the hemodynamic management of patients with acute traumatic spinal cord injury (SCI). Hemodynamic management, particularly augmenting mean arterial pressure (MAP), aims to improve blood perfusion and oxygen delivery to the injured spinal cord. The guideline provides recommendations on the target range for MAP (both upper and lower limits), the duration of MAP augmentation, and the choice of vasopressor. These recommendations are based on a systematic review of literature and clinical expertise. The guideline suggests augmenting MAP to at least 75-80 mmHg as a lower limit and not exceeding 90-95 mmHg as an upper limit. MAP augmentation should be maintained for 3-7 days. The choice of vasopressor is left to the treating physician's discretion.

Study Duration

Not specified

Participants

Multidisciplinary guideline development group

Evidence Level

Clinical practice guideline development following the GRADE process

Key Findings

1
The guideline suggests that MAP should be augmented to at least 75-80 mmHg as the “lower limit” in acute traumatic SCI patients.
2
An “upper limit” of 90-95 mmHg is recommended, beyond which active augmentation should not be pursued.
3
MAP should be augmented for a duration of 3-7 days after acute traumatic SCI.

Research Summary

This guideline updates the 2013 AANS/CNS recommendations on hemodynamic management of patients with acute traumatic SCI, incorporating literature published since 2011. The guideline development group (GDG) suggests specific MAP target ranges and durations for hemodynamic management, acknowledging the limitations of current evidence. The GDG felt that a recommendation on the choice of vasopressor or the use of SCPP targets was not warranted, given the dearth of available evidence.

Practical Implications

Blood Pressure Management

Provides updated recommendations for blood pressure management after acute SCI, recognizing the limitations of current evidence.

Clinical Practice

Offers a more practical and implementable guideline for clinicians managing acute SCI patients, with a broader MAP target range and duration.

Future Research

Highlights knowledge gaps and areas for future research, particularly regarding spinal cord perfusion pressure and choice of vasopressors.

Study Limitations

1
The quality of evidence around the “target MAP” was very low, and thus the strength of this recommendation is weak.
2
The quality of the evidence around the duration of MAP support was very low, and thus the strength of this recommendation is also weak.
3
The low quality of existing evidence and uncertainty around the relationship between MAP and neurologic recovery justified a greater range of MAP to target, and for a broader range of days post-injury than recommended in previous guidelines.

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