脊髓损伤后平均动脉压的维持：达到目标重要吗？

Mean arterial pressure maintenance following spinal cord injury: Does meeting the target matter?

机构信息

From the Department of Surgery (J.A.W., L.D.K., B.M.V., N.A.S., K.M.C.), Creighton University School of Medicine, St. Joseph's Hospital and Medical Center; Department of Neurosurgery (S.H.F., S.T.B., M.A.B., L.A.S.), Barrow Neurological Institute; and St. Joseph's Hospital and Medical Center, Phoenix, Arizona (J.J.R.).

出版信息

J Trauma Acute Care Surg. 2021 Jan 1;90(1):97-106. doi: 10.1097/TA.0000000000002953.

DOI:10.1097/TA.0000000000002953

PMID:33003016

Abstract

INTRODUCTION

Neurosurgical guidelines recommend maintaining mean arterial pressure (MAP) between 85 and 90 mm Hg following acute spinal cord injury (SCI). In our hospital, SCI patients receive orders for MAP targeting for 72 hours following admission, but it is unclear how often the patient's MAP meets the target and whether or not this affects outcome. We hypothesized that the proportion of MAP measurements ≥85 mm Hg would be associated with neurologic recovery.

METHODS

Spinal cord injury patients with blunt mechanism of injury admitted between 2014 and 2019 were identified from the registry of a level 1 trauma center. Proportion of MAP values ≥85 mm Hg was calculated for each patient. Neurologic improvement, as measured by positive change in American Spinal Injury Association (ASIA) impairment scale by ≥1 level from admission to discharge was evaluated with respect to proportion of elevated MAP values.

RESULTS

A total of 136 SCI patients were evaluated. Average proportion of elevated MAP values was 75%. Admission ASIA grades were as follows: A, 30 (22.1%); B, 20 (14.7%); C, 28 (20.6%); and D, 58 (42.6%). One hundred six patients (77.9%) required vasopressors to elevate MAP (ASIA A, 86.7%; B, 95.0%; C, 92.9%; D, 60.3%). Forty patients (29.4%) were observed to have improvement in ASIA grade by discharge (admission ASIA A, 15%; B, 33%; C, 40%; D, 13%). The proportion of elevated MAP values was higher for patients with neurologic improvement (0.81 ± 0.15 vs. 0.72 ± 0.25, p = 0.014). Multivariate modeling demonstrated a significant association between proportion of elevated MAP values and neurologic improvement (p = 0.028). An interaction revealed this association to be moderated by vasopressor dose (p = 0.032).

CONCLUSION

The proportion of MAP measurements ≥85 mm Hg was determined to be an independent predictor of neurologic improvement. Increased vigilance regarding MAP maintenance above 85 mm Hg is warranted to optimize neurologic recovery following SCI.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.

摘要

简介

神经外科学指南建议在急性脊髓损伤（SCI）后将平均动脉压（MAP）维持在 85 至 90mmHg 之间。在我们医院，SCI 患者在入院后 72 小时内接受 MAP 靶向治疗的医嘱，但尚不清楚患者的 MAP 有多少次达到目标，以及这是否会影响结果。我们假设 MAP 测量值≥85mmHg 的比例与神经恢复有关。

方法

从一级创伤中心的登记处确定了 2014 年至 2019 年间钝器机制损伤的脊髓损伤患者。计算了每位患者 MAP 值≥85mmHg 的比例。根据入院至出院时美国脊髓损伤协会（ASIA）损伤量表的阳性变化≥1 级，评估 MAP 值升高比例与神经改善之间的关系。

结果

共评估了 136 例 SCI 患者。MAP 值升高的平均比例为 75%。入院时的 ASIA 分级如下：A 级 30 例（22.1%）；B 级 20 例（14.7%）；C 级 28 例（20.6%）；D 级 58 例（42.6%）。为了升高 MAP，106 例患者（77.9%）需要使用血管加压药（ASIA A 级，86.7%；B 级，95.0%；C 级，92.9%；D 级，60.3%）。40 例患者（29.4%）出院时 ASIA 分级改善（入院时 ASIA A 级，15%；B 级，33%；C 级，40%；D 级，13%）。神经改善患者 MAP 值升高的比例较高（0.81±0.15 比 0.72±0.25，p=0.014）。多变量建模显示，MAP 值升高的比例与神经改善之间存在显著关联（p=0.028）。交互作用显示，这种关联受血管加压药剂量的调节（p=0.032）。