Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA.
Department of Pharmacy, University of Maryland Medical Center, University of Maryland School of Medicine, Baltimore, MD, USA.
Neurocrit Care. 2022 Jun;36(3):840-845. doi: 10.1007/s12028-021-01384-0. Epub 2021 Nov 29.
Acute cervical spinal cord injury (ACSCI) is commonly complicated by spinal shock, resulting in hemodynamic instability characterized by bradycardia and hypotension that can have fatal consequences. Current guidelines recommend the use of intravenous beta and dopamine agonists, such as norepinephrine and dopamine, respectively. We sought to determine whether enteral albuterol would be a safe and feasible treatment for bradycardia without an increase in the occurrence of known side effects of albuterol in patients with ACSCI.
A retrospective review of patients with ACSCI admitted to an intensive care unit at a level I trauma center and treated with enteral albuterol was conducted. Patients were excluded for the following reasons: pure beta blocker use prior to injury, concurrent use of pacemaker, age of less than 18 years, or age more than 75 years. As part of the standard of care, all patients underwent mean arterial pressure (MAP) augmentation to reach a goal of greater than 85 mm Hg during the first 7 days post injury. All eligible patient charts were reviewed for demographic characteristics, daily minimum and maximum heart rate and MAP, and concomitant vasoactive medication use. Bradycardia and tachycardia were defined as heart rate less than 60 beats per minute (bpm) and greater than 100 bpm, respectively. Factors found to be associated with bradycardia on univariate analysis were entered into a multivariable generalized estimating equation analysis to determine factors independently associated with bradycardia during the study period.
There were 58 patients with cervical ASCI (age 45 ± 18 years, 76% men) admitted between January 1, 2016, and December 31, 2017, that met the study criteria. The mean time to initiation of albuterol was 1.5 ± 1.7 days post injury, with a duration of 9.3 ± 4.5 days and a mean daily dosage of 7.8 ± 4.5 mg. Bradycardia was observed in 136 of 766 patient days (17%). There were a few episodes of hyperglycemia (1%) and tachycardia (3%), but no episodes of hypokalemia. In a multivariable analysis, female sex (P = 0.006) and American Spinal Cord Injury Association grade A, B, or C (P < 0.001) were associated with a higher risk of developing bradycardia, whereas dosage of albuterol (P = 0.009) and norepinephrine use (P = 0.008) were associated with a lower risk of developing bradycardia.
Albuterol administration in ASCI is a safe and feasible treatment for bradycardia, given that no significant side effects, such as hyperglycemia, hypokalemia, or tachycardia, were observed. The administration of enteral albuterol was well tolerated and, in a dose-dependent manner, associated with a lower occurrence of bradycardia. Further prospective trials for the use of enteral albuterol after SCI are warranted.
急性颈脊髓损伤（ACSCI）常伴有脊髓休克，导致血流动力学不稳定，表现为心动过缓和低血压，可能产生致命后果。目前的指南建议使用静脉内β和多巴胺激动剂，如去甲肾上腺素和多巴胺。我们旨在确定肠内使用沙丁胺醇是否是一种安全且可行的治疗心动过缓的方法，而不会增加 ACSCI 患者已知的沙丁胺醇副作用的发生。
对在一级创伤中心的重症监护病房接受肠内沙丁胺醇治疗的 ACSCI 患者进行回顾性分析。排除以下原因的患者：损伤前单纯使用β受体阻滞剂、同时使用起搏器、年龄小于 18 岁或大于 75 岁。作为标准治疗的一部分，所有患者在损伤后 7 天内接受平均动脉压（MAP）升高治疗，以达到大于 85mmHg 的目标。回顾所有符合条件的患者图表，以获取人口统计学特征、每日最低和最高心率和 MAP 以及同时使用的血管活性药物。心动过缓定义为心率小于 60 次/分钟（bpm），心动过速定义为心率大于 100bpm。单变量分析中发现与心动过缓相关的因素被纳入多变量广义估计方程分析，以确定研究期间与心动过缓相关的独立因素。
2016 年 1 月 1 日至 2017 年 12 月 31 日期间，共有 58 例颈脊髓损伤患者（年龄 45±18 岁，76%为男性）符合研究标准。沙丁胺醇的起始时间平均为损伤后 1.5±1.7 天，持续时间为 9.3±4.5 天，平均每日剂量为 7.8±4.5mg。766 个患者日中有 136 个（17%）观察到心动过缓。有少数高血糖（1%）和心动过速（3%）病例，但没有低钾血症病例。多变量分析显示，女性（P=0.006）和美国脊髓损伤协会 A、B 或 C 级（P<0.001）与发生心动过缓的风险较高相关，而沙丁胺醇剂量（P=0.009）和去甲肾上腺素的使用（P=0.008）与发生心动过缓的风险较低相关。
鉴于未观察到明显的副作用，如高血糖、低钾血症或心动过速，肠内给予沙丁胺醇治疗 ACSCI 是一种安全可行的方法。肠内给予沙丁胺醇耐受性良好，且呈剂量依赖性，与心动过缓的发生频率较低相关。需要进一步进行前瞻性试验以评估 SCI 后肠内使用沙丁胺醇的效果。
