Mean Arterial Pressure Goal Research Articles

An Update on Spinal Cord Injury and Current Management

» Spinal cord injury is associated with increased lifelong cost and decreased life expectancy.» Current treatment guidelines have been limited to studies of small effect sizes and limited availability of randomized control trials.» Recovery is best correlated with the initial American Spinal Injury Association impairment scale grade with A and B less likely to recover regarding ambulation as compared with C and D grades.» Surgical intervention within less than 24 hours, especially in the cervical spine, has been associated with some motor improvement.» The use of mean arterial pressure goals and steroids to maintain perfusion and decrease secondary injury requires further study to elucidate clearer evidence-based results.

Critical Care of Spinal Cord Injury.

Spinal cord injury (SCI) is a major cause of morbidity and mortality, posing a significant financial burden on patients and the healthcare system. While little can be done to reverse the primary mechanical insult, minimizing secondary injury due to ischemia and inflammation and avoiding complications that adversely affect neurologic outcome represent major goals of management. This article reviews important considerations in the acute critical care management of SCI to improve outcomes. Neuroprotective agents, such as riluzole, may allow for improved neurologic recovery but require further investigation at this time. Various forms of neuromodulation, such as transcranial magnetic stimulation, are currently under investigation. Early decompression and stabilization of SCI is recommended within 24h of injury when indicated. Spinal cord perfusion may be optimized with a mean arterial pressure goal from a lower limit of 75-80 to an upper limit of 90-95mmHg for 3-7days after injury. The use of corticosteroids remains controversial; however, initiation of a 24-h infusion of methylprednisolone 5.4mg/kg/hour within 8h of injury has been found to improve motor scores. Attentive pulmonary and urologic care along with early mobilization can reduce in-hospital complications.

Microbubble Contrast-Enhanced Transcutaneous Ultrasound Enables Real-Time Spinal Cord Perfusion Monitoring Following Posterior Cervical Decompression

Ultrasound imaging is inexpensive, portable, and widely available. The development of a real-time transcutaneous spinal cord perfusion monitoring system would allow more precise targeting of mean arterial pressure goals following acute spinal cord injury (SCI). There has been no prior demonstration of successful real-time cord perfusion monitoring in humans. Four adult patients who had undergone posterior cervical decompression and instrumentation at a single center were enrolled into this prospective feasibility study. All participants had undergone cervical laminectomies spanning ≥2 contiguous levels ≥2months prior to inclusion with no history of SCI. The first 2 underwent transcutaneous ultrasound without contrast and the second 2 underwent contrast-enhanced ultrasound (CEUS) with intravenously injected microbubble contrast. Using noncontrast ultrasound with or without Doppler (n= 2), the dura, spinal cord, and vertebral bodies were apparent however ultrasonography was insufficient to discern intramedullary perfusion or clear white-gray matter differentiation. With application of microbubble contrast (n= 2), it was possible to quantify differential spinal cord perfusion within and between cross-sectional regions of the cord. Further, it was possible to quantify spinal cord hemodynamic perfusion using CEUS by measuring peak signal intensity and the time to peak signal intensity after microbubble contrast injection. Time-intensity curves were generated and area under the curves were calculated as a marker of tissue perfusion. CEUS is a viable platform for monitoring real-time cord perfusion in patients who have undergone prior cervical laminectomies. Further development has the potential to change clinical management acute SCI by tailoring treatments to measured tissue perfusion parameters.

Assessing the optimal MAP target in pre-capillary PH patients with RV failure: A retrospective analysis.

Right ventricular failure (RVF) in pre-capillary pulmonary hypertension (PH) is associated with high morbidity and mortality. While mean arterial pressure (MAP) goals have been well established in critical care literature, the optimal MAP target for patients with RVF secondary to pre-capillary PH remains unknown. The objective of this study was to evaluate the difference in outcomes between patients who were managed with different MAP targets. We retrospectively analyzed records of 60 patients who were admitted to the intensive care unit for decompensated RVF secondary to pre-capillary PH. The records were stratified into two groups: 30 patients who were treated with a static MAP goal of either 65 or 70 mmHg (MAP65/70) and 30 patients who received a dynamic MAP goal (MAPCVP) determined by invasively obtained central venous pressure or right atrial pressure. The dynamic MAP group had a statistically significant decrease in in-hospital mortality and incidence of acute kidney injury compared to the static MAP cohort.

Blood component resuscitative strategies to mitigate endotheliopathy in a murine hemorrhagic shock model.

Resuscitation with plasma components has been shown to improve endotheliopathy induced by hemorrhagic shock, but the optimal resuscitation strategy to preserve the endothelial glycocalyx has yet to be defined. The aim of this study was to determine if resuscitation with lactated Ringer's (LR), whole blood (WB), packed red blood cells (RBCs), platelet-rich plasma (PRP), platelet poor plasma, balanced RBC:PRP (1:1), or day 14 (d14) RBC would best minimize endothelial damage following shock. Male C57BL/6 mice were hemorrhaged to a goal mean arterial pressure of 25 mm Hg for 1 hour. Unshocked sham mice served as controls. Mice were then resuscitated with equal volumes of LR, WB, RBC, PRP, platelet poor plasma, 1:1, or d14 RBC and then sacrificed at 1, 4, or 24 hours (n = 5). Serum was analyzed for syndecan-1, ubiquitin C-terminal hydrolase L1, and cytokine concentrations. Lungs underwent syndecan-1 immunostaining, and lung injury scores were calculated after hematoxylin and eosin. Proteolytic cleavage of the endothelial glycocalyx was assessed by serum matrix metalloprotease 9 levels. Serum syndecan-1 and ubiquitin C-terminal hydrolase L1 levels were significantly increased following resuscitation with d14 RBC compared with other groups. Early elevation in lung syndecan-1 staining was noted in LR-treated mice, while d14 mice showed decreased staining compared with sham mice following shock. Lung injury scores were significantly elevated 4 hours after resuscitation with LR and d14 RBC compared with WB. Serum matrix metalloprotease 9 levels were significantly increased at 1 and 4 hours in d14 mice compared with sham mice. Systemic inflammation was increased in animals receiving LR, 1:1, or d14 RBC. Resuscitation with WB following hemorrhagic shock reduces endothelial syndecan-1 shedding and mitigates lung injury. Aged RBC and LR fail to attenuate endothelial injury following hemorrhagic shock. Further research will be necessary to determine the effect of each of these resuscitative fluids in a hemorrhagic shock model with the addition of tissue injury.

Evaluation of Dose Requirements Using Weight-Based versus Non-Weight-Based Dosing of Norepinephrine to Achieve a Goal Mean Arterial Pressure in Patients with Septic Shock

No consensus exists regarding optimal dosing of norepinephrine in septic shock. We aimed to evaluate if weight-based dosing (WBD) lead to higher norepinephrine doses when achieving goal mean arterial pressure (MAP) than non-weight-based dosing (non-WBD). This was a retrospective cohort study conducted after standardization of norepinephrine dosing within a cardiopulmonary ICU. Patients received non-WBD prior to standardization (November 2018-October 2019) and WBD afterwards (November 2019-October 2020). The primary outcome was the norepinephrine dose needed to attain goal MAP. Secondary outcomes included time to goal MAP, duration of norepinephrine therapy, duration of mechanical ventilation, and treatment-related adverse effects. A total of 189 patients were included (WBD 97; non-WBD 92). There was a significantly lower norepinephrine dose at goal MAP (WBD 0.05, IQR 0.02, 0.07; non-WBD 0.07, IQR 0.05, 0.14; p < 0.005) and initial norepinephrine dose (WBD 0.02, IQR 0.01, 0.05; non-WBD 0.06, 0.04, 0.12; p < 0.005) in the WBD group. No difference was observed in achievement of goal MAP (WBD 73%; non-WBD 78%; p = 0.09) or time until goal MAP (WBD 18, IQR 0, 60; non-WBD 30, IQR 14, 60; p = 0.84). WBD may lead to lower norepinephrine doses. Both strategies achieved goal MAP with no significant difference in time to goal.

The incidence of cardiovascular instability in patients receiving various vasopressor strategies for peri-intubation hypotension

IntroductionPatients frequently experience hypotension in the peri-intubation period. This can be due to the underlying disease process, physiologic response to the intervention, or adverse effect from medications. With the heterogeneity in cause for hypotension, the duration can also be short or prolonged. Initiation of vasopressors for peri-intubation hypotension includes various strategies using continuous infusion norepinephrine (NE) or push-dose phenylephrine (PDPE) to obtain goal mean arterial pressure. There is a paucity of data describing cardiovascular stability outcomes in patients receiving vasopressors for peri-intubation hypotension. MethodsThis is a retrospective cohort study including emergency department patients across three academic medical centers and smaller health system sites who received vasopressors for hypotension within 30 min of intubation. Patients were matched based on factors likely to influence vasopressor selection and were divided into groups if they received PDPE alone, continuous infusion NE alone, or PDPE followed by continuous infusion NE. The primary outcome was a composite of the incidence of hypotension (systolic blood pressure < 90 mmHg), bradycardia (HR < 60 beats per minute), and cardiac arrest within 2 h following initiation of vasopressors. ResultsScreening occurred for 2518 patients, with 105 patients undergoing matching. Mean time to vasopressor initiation was 10 min following intubation. The composite primary outcome was not statistically different between groups and occurred 88.6%, 80.0%, and 88.6% in the NE, PDPE, and PDPE+NE groups, respectively. A subgroup analysis of patients with an ED diagnosis of sepsis or septic shock were more likely to receive PDPE before starting continuous infusion NE (41.3% vs. 27.1%, p = 0.075) and more frequently experienced the primary composite outcome (p = 0.045) but was not correlated with vasopressor strategy (p = 0.55). DiscussionCardiovascular instability following vasopressor initiation for peri-intubation hypotension was no different depending on the selected vasopressor strategy. This held true in patients with a sepsis or septic shock diagnosis. Selection of vasopressors should continue to include patient specific factors and product availability.

815: TIME TO HEMODYNAMIC STABILITY AFTER IMPLEMENTATION OF A NOREPINEPHRINE RAPID TITRATION PROTOCOL

Introduction: Norepinephrine (NE) is the primary vasoactive medication for many different shock states and is titrated to have a hemodynamic effect. A rapid titration protocol was recently implemented at our institution to provide nurses the ability to quickly titrate NE and comply with Joint Commission regulations. The purpose of this study is to evaluate whether implementing a rapid titration protocol for NE impacted time to hemodynamic stability in critically ill patients. Methods: A single-center, retrospective study of adult ICU patients receiving NE as a first line agent at a large academic medical center was performed. The patients were categorized into the pre-implementation group with standard titration instructions from April 2022 and the post implementation group with the rapid titration instructions from July 2022. Our primary outcome was to evaluate the time to hemodynamic stability based on mean arterial pressure (MAP) goals. Secondary outcomes included ICU and hospital length of stay (LOS), all-cause mortality and safety outcomes with NE administration. Results: A total of 64 patients were included in our analysis, of which, 30 patients were included in the pre-implementation group and 34 in the post-implementation group. Baseline characteristics were similar in both the groups, including NE starting rate (0.07 mcg/kg/min vs 0.08 mcg/kg/min, p=0.9), and Modified Early Warning Score (5 vs. 4, p=0.07). The primary outcome of time to hemodynamic stability based on MAP did not differ between the groups (median 12.5 minutes [IQR 0-28] vs. 11.5 minutes [IQR 0-36], p=0.7). However, the rapid titration group received significantly less concomitant IV vasopressors in the first 24 hours (50% vs. 18%, p=0.006) and experienced longer time to second vasopressor initiation (median 2.5 hours [IQR 0.10-3.6] vs. 10 hours [IQR 2.5-20]). Conclusions: At our institution, rapid titration instructions for NE did not shorten time to hemodynamic stability compared to the standard titration protocol. Our study shows that utilizing the NE rapid titration protocol may be safe and may reduce the need for an additional vasopressor. Further prospective studies are warranted to assess compliance with implementing a rapid titration protocol and its potential benefits.

Timing of Vasopressin Addition to Norepinephrine and Efficacy Outcomes in Patients With Septic Shock.

Current guidelines recommend norepinephrine as the first-line vasopressor in septic shock followed by addition of vasopressin to achieve a goal mean arterial pressure. Limited evidence exists evaluating how the timing of vasopressin addition affects clinical outcomes in septic shock. The objective of this study was to determine whether the timing of the addition of vasopressin to norepinephrine affects shock resolution. This was a multi-site, single system, retrospective cohort, institutional review board (IRB)-approved study examining adult patients with septic shock who received norepinephrine and vasopressin. Patients were divided and statistically analyzed in two subgroups: early vasopressin addition (<3 hours) and late vasopressin addition (≥3 hours). The primary outcome was time to shock resolution, defined as vasopressor free for at least 24 hours. Secondary outcomes included norepinephrine dose at 3 hours after initiation of vasopressin, in-hospital mortality, and intensive care unit length of stay. A total of 243 patients were included in this study. A statistically significant decrease in time to shock resolution was observed in the early vasopressin addition group compared to the late vasopressin addition group (37.6 hours vs 60.7 hours; adjusted hazard ratio [HR]: 2.07 [1.48-2.89; P = <0.001]). The early addition of vasopressin did not affect norepinephrine dose or in-hospital mortality but did lead to a decreased intensive care unit (ICU) length of stay (4.3 days vs 5.3 days, P = 0.02). Addition of vasopressin to norepinephrine within 3 hours was associated with a faster time to shock resolution. These findings suggest a potential for improved clinical outcomes with earlier vasopressin addition.

Contemporary hemodynamic management of acute spinal cord injuries with intravenous and enteral vasoactive agents: A narrative review.

The pathophysiology and hemodynamic management of acute spinal cord injuries, including the use of intravenous and enteral vasoactive agents, are reviewed. Spinal cord injuries are devastating neurological insults that in the acute setting lead to significant hemodynamic disturbances, including hypotension and bradycardia, that are influenced by the level of injury. High thoracic (usually defined as at or above T6) and cervical injuries often manifest with hypotension and bradycardia due to destruction of sympathetic nervous system activity and unopposed vagal stimulation to the myocardium, whereas lower thoracic injuries tend to result in hypotension alone due to venous pooling. Initial management includes maintaining euvolemia with crystalloids and maintaining or augmenting mean arterial pressure with the use of intravenous vasoactive agents to improve neurological outcomes. Choice of vasopressor should be based on patient-specific factors, particularly level of injury and presenting hemodynamics. This review includes the most recent literature on intravenous vasopressors as well as the limited evidence supporting the use of enteral vasoactive agents. Enteral vasoactive agents may be considered, when clinically appropriate, as a strategy to wean patients off of intravenous agents and facilitate transfer outside of the intensive care unit. The hemodynamic management of acute spinal cord injuries often requires the use of vasoactive agents to meet mean arterial pressure goals and improve neurological outcomes. Patient-specific factors must be considered when choosing intravenous and enteral vasoactive agents.

Mean Arterial Pressure Goal in Critically Ill Patients: A Meta-Analysis of Randomized Controlled Trials

BackgroundCurrent guidelines recommend targeting a mean arterial pressure (MAP) goal of 65 mm Hg or more in critically ill medical patients. Prospective studies have shown that a higher MAP goal can improve survival and decrease end-organ damage. However, randomized controlled trials (RCTs) have failed to show similar results. Thus, we performed this meta-analysis to evaluate whether a high MAP goal compared to a standard or low MAP goal will improve clinical outcomes in critically ill medical patients.MethodsWe searched electronic databases for RCTs comparing standard MAP goals versus high MAP goals in critically ill medical patients. A standard MAP goal was defined as a MAP of 60 - 70 mm Hg, and a MAP of 70 mm Hg or more was considered a high MAP goal. Outcomes of interest were mortality, duration of mechanical ventilation, and intensive care unit (ICU) length of stay. Subgroup analysis was performed based on the type of critically ill patients: cardiac arrest and septic shock. We used random-effects meta-analysis to estimate risk ratio (RR) with a 95% confidence interval (CI) for a dichotomous outcome. For continuous outcomes, the inverse variance method was used to calculate the standardized mean difference (SMD) with 95% CI. A P value of 0.05 or less was considered significant.ResultsSix RCTs with a total of 3,753 patients (standard MAP goal: n = 1,872 and high MAP goal: n = 1,881) were included in the final analysis. Both standard/low MAP goal and high MAP goal were associated with similar risk for mortality (RR 0.94, 95% CI (0.87, 1.01), P = 0.11), duration of mechanical ventilation (SMD 0.51, 95% CI (-0.29, 1.31), P = 0.21) and ICU length of stay (SMD 0.22, 95% CI (-0.07, 0.5), P = 0.14). Subgroup analysis in cardiac arrest patient showed decreased ICU stay (SMD 0.55, 95% CI (0.31, 0.80), P < 0.000001) in patients with higher MAP goal compared to the standard MAP goal group without any difference in mortality or duration of mechanical ventilation. Subgroup analysis of patients with septic shock had similar outcomes in both MAP targets.ConclusionsIn critically ill patients, a higher MAP goal of > 70 mm Hg was associated with a similar risk of mortality, duration of mechanical ventilation, and ICU length of stay when compared with a standard MAP goal of 60 - 70 mm Hg.

Normothermic regional perfusion surgical technique for the procurement of cardiac donors after circulatory death.

Normothermic regional perfusion surgical technique for the procurement of cardiac donors after circulatory death.

Investigational Therapies for Gunshot Wounds to the Spine: A Narrative Review.

This was a narrative review. The objective of this study was to review the standards of care and triage protocol for gunshot wounds to the spine, highlighting innovative future treatment options that may be implemented in patients with spinal cord injury (SCI). With the increased availability of firearms among the United States population, gunshot wounds to the spine are becoming a clinically relevant and devastating issue. Such injuries result in severe and diverse complications. SCIs due to gunshot wounds are the leading cause of morbidity and mortality, as they often result in complete or incomplete paraplegia. Current standards of care focus on preventing further damage rather than total cure or treatment of SCI. A literature review was performed on the standards of care, triage protocol, associated conditions, current therapeutic options, and innovative treatment options for patients with gunshot wounds to the spine. The general standards of care for spinal gunshot wounds involve maintaining or renewal of mechanical spinal steadiness and neurological activity while limiting complications of treatment. Current treatment options include management of mean arterial pressure goals, drug therapies consisting of antibiotics, and surgical approaches. With recent innovations in molecular biology and cell transplantation, potentially new and promising treatment options for patients with SCI exist. These options include cell transplantation therapies, platelet-rich plasma administration, exosomal treatments, and mitochondrial-targeted therapeutics. Stem cell transplantation is promising, as several clinical studies have been completed. However, loss-to-follow-up, lack of long-term evaluation, and questionable randomization has limited the use of stem cells in the standard of care practice. Although not studied on human models to a gunshot wound, exosomal and mitochondrial-based treatment options have been studied both in vitro and in animal models with SCI. Newly emerging molecular and cellular therapy modalities for SCI contribute to the recovery process and may be utilized in conjunction with the current modalities for better outcomes.

Blood product resuscitation mitigates the effects of aeromedical evacuation after polytrauma.

The combined injury of traumatic brain injury and hemorrhagic shock has been shown to worsen coagulopathy and systemic inflammation, thereby increasing posttraumatic morbidity and mortality. Aeromedical evacuation to definitive care may exacerbate postinjury morbidity because of the inherent hypobaric hypoxic environment. We hypothesized that blood product resuscitation may mitigate the adverse physiologic effects of postinjury flight. An established porcine model of controlled cortical injury was used to induce traumatic brain injury. Intracerebral monitors were placed to record intracranial pressure, brain tissue oxygenation, and cerebral perfusion. Each of the 42 pigs was hemorrhaged to a goal mean arterial pressure of 40 ± 5 mm Hg for 1 hour. Pigs were grouped according to resuscitation strategy used-Lactated Ringer's (LR) or shed whole blood (WB)-then placed in an altitude chamber for 2 hours at ground, 8,000 ft, or 22,000 ft, and then observed for 4 hours. Hourly blood samples were analyzed for proinflammatory cytokines and lactate. Internal jugular vein blood flow was monitored continuously for microbubble formation with altitude changes. Cerebral perfusion, tissue oxygenation, and intracranial pressure were unchanged among the six study groups. Venous microbubbles were not observed even with differing altitude or resuscitation strategy. Serum lactate levels from hour 2 of flight to the end of observation were significantly elevated in 22,000 + LR compared with 8,000 + LR and 22,000 + WB. Serum IL-6 levels were significantly elevated in 22,000 + LR compared with 22,000 + WB, 8,000 + LR and ground+LR at hour 1 of observation. Serum tumor necrosis factor-α was significantly elevated at hour 2 of flight in 8,000 + LR versus ground+LR, and in 22,000 + LR vs. 22,000 + WB at hour 1 of observation. Serum IL-1β was significantly elevated hour 1 of flight between 8,000 + LR and ground+LR. Crystalloid resuscitation during aeromedical transport may cause a prolonged lactic acidosis and proinflammatory response that can predispose multiple-injury patients to secondary cellular injury. This physiologic insult may be prevented by using blood product resuscitation strategies.

Effect of Phenylephrine Push Before Continuous Infusion Norepinephrine in Patients With Septic Shock

IV pushes of phenylephrine may be used for patients with septic shock with the intent of rapidly achieving mean arterial pressure (MAP) goals. However, the clinical effectiveness and safety of this approach are unclear. In patients with septic shock, is administration of a phenylephrine push before norepinephrine initiation associated with a higher incidence of hemodynamic stability? This retrospective, multicenter cohort study included adult patients with septic shock initiated on norepinephrine. Propensity scores for initial phenylephrine push receipt were generated, and patients receiving an initial phenylephrine push were propensity score-matched 1:2 to those not receiving an initial phenylephrine push. The primary outcome was achievement of hemodynamic stability (defined as maintaining MAP of≥ 65mmHg for at least 6h without an increase in continuous infusion vasoactive agent dosage) within 3 and 12h of norepinephrine initiation. Of 1,317 included patients, 181 received an initial phenylephrine push; 141 phenylephrine push patients were matched to 282 patients not receiving a phenylephrine push. More patients who received a phenylephrine push achieved hemodynamic stability at hour 3 than those who did not receive a phenylephrine push (28.4%vs18.8%; risk difference, 10%; 95%CI, 0.9%-18%). Phenylephrine push receipt was associated independently with hemodynamic stability within 3h (adjusted OR, 1.8; 95%CI, 1.09-2.97), but not at 12h (adjusted OR, 1.42; 95%CI, 0.93-2.16). Phenylephrine push receipt was associated independently with higher ICU mortality (adjusted OR, 1.88; 95%CI, 1.1-3.21). Phenylephrine pushes were associated with a higher incidence of early, but not sustained, hemodynamic stability and were associated independently with higher ICU mortality. Caution is warranted when clinicians are considering the use of phenylephrine pushes in patients with septic shock.

Lumbar Drains After Cardiac Surgery: Evidence-Based Solutions for Safe Management.

Lumbar Drains After Cardiac Surgery: Evidence-Based Solutions for Safe Management.

The Effect of Elevated Mean Arterial Blood Pressure in Cervical Traumatic Spinal Cord Injury with Hemorrhagic Contusion

Hemorrhagic contusion in cervical spinal cord injury (CSCI) is poorly understood. We investigated hemorrhagic expansion in patients with CSCI with an assigned elevated mean arterial pressure (MAP) goal of >85 mm Hg. The change in hemorrhagic area and long-term follow-up data ≥6 months after injury was studied. A retrospective review was performed from 2005 to 2016 to identify patients with motor complete CSCI with 2 cervical magnetic resonance imaging (MRI) scans within 7 days of injury showing evidence of hemorrhagic contusion and assigned a MAP goal of >85 mm Hg for 7 days. T2-weighted MRI was used to calculate the hemorrhagic surface area in the sagittal plane. A calculated MAP was recorded for each blood pressure measure between the initial and follow-up MRI scans. The American Spinal Injury Association impairment scale (AIS) and American Spinal Injury Association motor scores were recorded at the final follow-up examination at ≥6 months. A total of 193 patients were identified. The mean change in the hemorrhagic area was 24.0 mm2. Of the 193 patients, the AIS grade was A for 114 and B for 79 patients. Multiple logistic regression analysis demonstrated that the MAP and systolic blood pressure were nonsignificant predictors of hemorrhagic contusion expansion. An increased hemorrhagic contusion area on the follow-up MRI scan was associated with a reduced odds of AIS improvement of ≥1 and ≥2 points (odds ratio, 0.97; 95% confidence interval, 0.87-0.97; P= 0.028; and odds ratio, 0.92; 95% confidence interval, 0.99-1.13; P= 0.008, respectively) at the final ≥6-month follow-up examination. The present study investigated the clinical safety of elevated MAP goals for patients with CSCI and hemorrhagic contusion. Elevated MAPs did not significantly increase the risk of hemorrhagic expansion in those with CSCI. We have also reported the use of hemorrhagic contusion size as a potential radiographic biomarker for neurological outcomes.

Care for patients with ventricular assist devices and suspected COVID-19 infection.

Care for patients with ventricular assist devices and suspected COVID-19 infection.

Clinical Implementation of Novel Spinal Cord Perfusion Pressure Protocol in Acute Traumatic Spinal Cord Injury at U.S. Level I Trauma Center: TRACK-SCI Study

We sought to report the safety of implementation of a novel standard of care protocol using spinal cord perfusion pressure (SCPP) maintenance for managing traumatic spinal cord injury (SCI) in lieu of mean arterial pressure goals at a U.S. Level I trauma center. Starting in December 2017, blunt SCI patients presenting <24 hours after injury with admission American Spinal Injury Association Impairment Scale (AIS) A-C (or AIS D at neurosurgeon discretion) received lumbar subarachnoid drain (LSAD) placement for SCPP monitoring in the intensive care unit and were included in the TRACK-SCI (Transforming Research and Clinical Knowledge in Spinal Cord Injury) data registry. This SCPP protocol comprises standard care at our institution. SCPPs were monitored for 5 days (goal ≥65 mm Hg) achieved through intravenous fluids and vasopressor support. AISs were assessed at admission and day7. Fifteen patients enrolled to date were aged 60.5 ± 17 years. Injury levels were 93.3% (cervical) and 6.7% (thoracic). Admission AIS was 20.0%/20.0%/26.7%/33.3% for A/B/C/D. All patients maintained mean SCPP ≥65 mm Hg during monitoring. Fourteen of 15 cases required surgical decompression and stabilization with time to surgery 8.8 ± 7.1 hours (71.4% <12 hours). At day 7, 33.3% overall and 50% of initial AIS A-C had an improved AIS. Length of stay was 14.7 ± 8.3 days. None had LSAD-related complications. There were 7 respiratory complications. One patient expired after transfer to comfort care. In our initial experience of 15 patients with acute SCI, standardized SCPP goal-directed care based on LSAD monitoring for 5 days was feasible. There were no SCPP-related complications. This is the first report of SCPP implementation as clinical standard of care in acute SCI.

Initial Experience of Spinal Cord Perfusion Pressure Goals in Lieu of Mean Arterial Pressure Goals in Acute Traumatic Spinal Cord Injury at a United States Level I Trauma Center: A Transforming Research and Clinical Knowledge-Spinal Cord Injury Study

Abstract INTRODUCTION Management of traumatic spinal cord injury (SCI) includes urgent decompression and decreasing secondary injury through blood pressure augmentation. Mean arterial pressure (MAP) targets have been the standard of care for decades, however recent clinical trial data have demonstrated the relationship between spinal cord perfusion pressure (SCPP) and neurologic recovery. These data led to implementation of a novel standard of care protocol at our institution focused on SCPP, in lieu of MAP goals. We provide the initial experience of implementation of protocolized SCPP goals for acute SCI at a US level I trauma center. METHODS Starting December 2017, all moderate/severe blunt SCI patients at our institution presenting &lt; 24 h of injury received lumbar subarachnoid drain placement (LSAD) for intraspinal pressure (ISP) and SCPP monitoring in the neurological intensive care unit (NICU), and were included in the Transforming Research and Clinical Knowledge in Spinal Cord Injury (TRACK-SCI) data registry. This is known as the SCPP Protocol, and comprises standard care at our institution. SCPPs were monitored for 5 d with goal = 65 mmHg achieved through intravenous fluids and vasopressor support. American Spinal Injury Association Impairment Scale (AIS) grades were assessed at admission and day 7. RESULTS In 15 patients enrolled to date, age was 60.5 ± 17.0 yr and 46.7% were = 65. Injury level was 93.3% cervical and 6.7% thoracic. Admission AIS were 20.0%/20.0%/26.7%/33.3% for A/B/C/D, respectively. A total of 14 patients underwent surgical decompression with time to surgery 8.8 ± 7.1 h and 71.4% &lt; 12 h. Hospital length of stay (LOS) was 14.7 ± 8.3 d. NICU LOS was 11.5 ± 8.9 d. No patient had lumbar drain-related complications. Seven patients had respiratory complications and 1 expired after family transitioned to comfort care. AIS grade improvement of 1 occurred in one-third of patients (2 AIS = B, 3 AIS = C). CONCLUSION In our initial experience of 15 patients with acute traumatic SCI, standardized SCPP goal-directed care through lumbar ISP monitoring for the first 5 d postinjury was feasible and without SCPP-related complications.