From the University Hospitals Case Medical Center (J.A.P., R.O.), Cleveland, Ohio; University of Michigan (J.A.P.), Ann Arbor, Michigan; University of Florida College of Medicine (A.J.K.), Jacksonville; University of Florida College of Medicine (L.L.), Gainesville; Orlando Regional Medical Center (M.L.C.), Orlando; and University of Miami Miller School of Medicine (P.M.B.), Miami, Florida; Jefferson Medical College (M.S.W.), Philadelphia, Pennsylvania; University of Maryland School of Medicine (D.M.S.), Baltimore, Maryland; West Virginia University School of Medicine (J.K.), Morgantown, West Virginia; Piedmont Hospital (S.K.), Atlanta, Georgia; Hackensack Medical Center (S.D.), Hackensack, New Jersey; Wayne State University School of Medicine (L.D.), Detroit, Michigan.
J Trauma Acute Care Surg. 2014 Feb;76(2):303-9; discussion 309-10. doi: 10.1097/TA.0000000000000112.
Ventilator-dependent spinal cord-injured (SCI) patients require significant resources related to ventilator dependence. Diaphragm pacing (DP) has been shown to successfully replace mechanical ventilators for chronic ventilator-dependent tetraplegics. Early use of DP following SCI has not been described. Here, we report our multicenter review experience with the use of DP in the initial hospitalization after SCI.
Under institutional review board approval for humanitarian use device, we retrospectively reviewed our multicenter nonrandomized interventional protocol of laparoscopic diaphragm motor point mapping with electrode implantation and subsequent diaphragm conditioning and ventilator weaning.
Twenty-nine patients with an average age of 31 years (range, 17-65 years) with only two females were identified. Mechanism of injury included motor vehicle collision (7), diving (6), gunshot wounds (4), falls (4), athletic injuries (3), bicycle collision (2), heavy object falling on spine (2), and motorcycle collision (1). Elapsed time from injury to surgery was 40 days (range, 3-112 days). Seven (24%) of the 29 patients who were evaluated for the DP placement had nonstimulatable diaphragms from either phrenic nerve damage or infarction of the involved phrenic motor neurons and were not implanted. Of the stimulatable patients undergoing DP, 72% (16 of 22) were completely free of ventilator support in an average of 10.2 days. For the remaining six DP patients, two had delayed weans of 180 days, three had partial weans using DP at times during the day, and one patient successfully implanted went to a long-term acute care hospital and subsequently had life-prolonging measures withdrawn. Eight patients (36%) had complete recovery of respiration, and DP wires were removed.
Early laparoscopic diaphragm mapping and DP implantation can successfully wean traumatic cervical SCI patients from ventilator support. Early laparoscopic mapping is also diagnostic in that a nonstimulatable diaphragm is a convincing evidence of an inability to wean from ventilator support, and long-term ventilator management can be immediately instituted.
Therapeutic study, level V.
依赖呼吸机的脊髓损伤（SCI）患者需要大量资源来维持呼吸机的使用。膈肌起搏（DP）已被证明可成功替代慢性呼吸机依赖四肢瘫痪患者的机械呼吸机。尚未描述 SCI 后早期使用 DP。在这里，我们报告了我们在 SCI 后初始住院期间使用 DP 的多中心回顾性经验。
根据机构审查委员会批准的人道主义使用设备，我们回顾性地审查了我们的多中心非随机干预性协议，该协议包括腹腔镜膈肌运动点映射、电极植入以及随后的膈肌调理和呼吸机脱机。
确定了 29 名平均年龄为 31 岁（范围，17-65 岁）的患者，其中仅 2 名女性。损伤机制包括机动车碰撞（7 例）、潜水（6 例）、枪伤（4 例）、跌倒（4 例）、运动损伤（3 例）、自行车碰撞（2 例）、重物落在脊柱上（2 例）和摩托车碰撞（1 例）。从受伤到手术的时间间隔为 40 天（范围，3-112 天）。在评估 DP 放置的 29 名患者中，有 7 名（24%）由于膈神经损伤或受累膈运动神经元梗死，膈肌无法刺激，因此未植入电极。在可刺激的接受 DP 治疗的患者中，72%（22 例中的 16 例）在平均 10.2 天内完全无需呼吸机支持。对于其余 6 名 DP 患者，有 2 名患者延迟脱机 180 天，3 名患者在白天的某些时间使用 DP 部分脱机，1 名成功植入的患者转至长期急性护理医院，随后停止了延长生命的措施。8 名患者（36%）呼吸完全恢复，DP 线被移除。
早期腹腔镜膈肌图谱绘制和 DP 植入可成功使创伤性颈 SCI 患者脱离呼吸机支持。早期腹腔镜图谱绘制也是一种诊断方法，因为无法刺激的膈肌是无法从呼吸机支持中脱机的有力证据，可以立即进行长期呼吸机管理。
治疗研究，5 级。
