Incidence of intraoperative hypotension in acute traumatic spinal cord injury and associated factors

Xavier P. Gaudin Division of Neurosurgery, OhioHealth Grant Medical Center, Columbus;

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Jacob C. Wochna Ohio University Heritage College of Osteopathic Medicine, Athens; and

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Timothy W. Wolff Division of Trauma and Acute Care Surgery, OhioHealth Grant Medical Center, Columbus, Ohio

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Sean M. Pugh Ohio University Heritage College of Osteopathic Medicine, Athens; and

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Urmil B. Pandya Division of Trauma and Acute Care Surgery, OhioHealth Grant Medical Center, Columbus, Ohio

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M. Chance Spalding Division of Trauma and Acute Care Surgery, OhioHealth Grant Medical Center, Columbus, Ohio

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Kailash K. Narayan Division of Neurosurgery, OhioHealth Grant Medical Center, Columbus;

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OBJECTIVE

The importance of maintaining mean arterial pressure (MAP) > 85 mm Hg for patients with acute spinal cord injury (SCI) is well documented, because systemic hypotension greatly increases the risk of secondary SCI. Current literature focuses on the ICU setting; however, there is a paucity of data describing the changes in MAP in the operating room (OR). In the present study, the authors investigated the incidence of intraoperative hypotension for patients with acute traumatic SCI as well as any associated factors that may have impacted these findings.

METHODS

This retrospective study was performed at a level 1 trauma center from 2015 to 2016. All patients with American Spinal Injury Association (ASIA) score A–D acute traumatic SCIs from C1 to L1 were identified. Those included underwent spinal instrumentation and/or laminectomy decompression. Associated factors investigated include the following: age, body mass index, trauma mechanism of injury, Injury Severity Score, level of SCI, ASIA score, hospital day of surgery, total OR time, need for laminectomy decompression, use of spinal fixation, surgical positioning, blood loss, use of blood products, length of hospital stay, length of ICU stay, and discharge disposition. Intraoperative minute-by-minute MAP recordings were used to determine time spent in various MAP ranges.

RESULTS

Thirty-two patients underwent a total of 33 operations. Relative to the total OR time, patients spent an average of 51.9% of their cumulative time with an MAP < 85 mm Hg. Furthermore, 100% of the study population recorded at least one MAP measurement < 85 mm Hg. These hypotensive episodes lasted a mean of 103 cumulative minutes per operative case. Analysis of associated factors demonstrated that fall mechanisms of injury led to a statistically significant increase in intraoperative hypotension compared to motor vehicle collisions/motorcycle collisions (p = 0.033). There were no significant differences in MAP recordings when analyzed according to all other associated factors studied.

CONCLUSIONS

This is the first study reporting the incidence of intraoperative hypotension for patients with acute traumatic SCIs, and the results demonstrated higher proportions of relative hypotension than previously reported in the ICU setting. Furthermore, the authors identified that every patient experienced at least one MAP below the target value, which was much greater than the initial hypothesis of 50%. Given the findings of this study, adherence to the MAP protocol intraoperatively needs to be improved to minimize the risk of secondary SCI and associated deleterious neurological outcomes.

ABBREVIATIONS

AANS = American Association of Neurological Surgeons; ASIA = American Spinal Injury Association; BMI = body mass index; CNS = Congress of Neurological Surgeons; ISS = Injury Severity Score; ITP = intrathecal pressure; MAP = mean arterial pressure; MOI = mechanism of injury; MVC/MC = motor vehicle collision/motorcycle collision; OR = operating room; SCI = spinal cord injury; SCPP = spinal cord perfusion pressure.

OBJECTIVE

The importance of maintaining mean arterial pressure (MAP) > 85 mm Hg for patients with acute spinal cord injury (SCI) is well documented, because systemic hypotension greatly increases the risk of secondary SCI. Current literature focuses on the ICU setting; however, there is a paucity of data describing the changes in MAP in the operating room (OR). In the present study, the authors investigated the incidence of intraoperative hypotension for patients with acute traumatic SCI as well as any associated factors that may have impacted these findings.

METHODS

This retrospective study was performed at a level 1 trauma center from 2015 to 2016. All patients with American Spinal Injury Association (ASIA) score A–D acute traumatic SCIs from C1 to L1 were identified. Those included underwent spinal instrumentation and/or laminectomy decompression. Associated factors investigated include the following: age, body mass index, trauma mechanism of injury, Injury Severity Score, level of SCI, ASIA score, hospital day of surgery, total OR time, need for laminectomy decompression, use of spinal fixation, surgical positioning, blood loss, use of blood products, length of hospital stay, length of ICU stay, and discharge disposition. Intraoperative minute-by-minute MAP recordings were used to determine time spent in various MAP ranges.

RESULTS

Thirty-two patients underwent a total of 33 operations. Relative to the total OR time, patients spent an average of 51.9% of their cumulative time with an MAP < 85 mm Hg. Furthermore, 100% of the study population recorded at least one MAP measurement < 85 mm Hg. These hypotensive episodes lasted a mean of 103 cumulative minutes per operative case. Analysis of associated factors demonstrated that fall mechanisms of injury led to a statistically significant increase in intraoperative hypotension compared to motor vehicle collisions/motorcycle collisions (p = 0.033). There were no significant differences in MAP recordings when analyzed according to all other associated factors studied.

CONCLUSIONS

This is the first study reporting the incidence of intraoperative hypotension for patients with acute traumatic SCIs, and the results demonstrated higher proportions of relative hypotension than previously reported in the ICU setting. Furthermore, the authors identified that every patient experienced at least one MAP below the target value, which was much greater than the initial hypothesis of 50%. Given the findings of this study, adherence to the MAP protocol intraoperatively needs to be improved to minimize the risk of secondary SCI and associated deleterious neurological outcomes.

In Brief

This was the first study to identify the incidence of intraoperative hypotension for patients with acute traumatic spinal cord injuries and to demonstrate that this relative hypotension occurred at a greater proportion than previously reported in the intensive care unit setting. This is important given that systemic hypotension can cause hypoperfusion of the spinal cord, leading to deleterious neurological outcomes associated with secondary spinal cord injury.

The incidence of traumatic spinal cord injuries (SCIs) in 2010 was approximately 12,400 in the United States, which was higher than in any other country in the world.3 One of the primary roles of the healthcare team in the setting of SCI is to minimize the progressive mechanisms of secondary SCIs. Secondary SCIs are precipitated by systemic hypotension, which itself is often a result of traumatic SCI.14 This can cause ischemia, hypoxia, edema, inflammation, and metabolic disturbances, and ultimately lead to worse clinical outcomes.1,16 Additionally, the frequency of hypotensive episodes during hospitalization correlates with the severity of SCI based on the American Spinal Injury Association (ASIA) motor score.9 To achieve optimal spinal cord perfusion, the American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS) published guidelines in 2013 for the management of SCI, recommending maintenance of a mean arterial pressure (MAP) of 85–90 mm Hg for the first 7 days following an acute SCI.11

Numerous studies support the significance of maintaining spinal cord perfusion in SCI. When MAP is maintained > 85 mm Hg, patients demonstrate improved ambulatory function, bowel and bladder function, and neurological recovery.16 However, studies have demonstrated that blood pressure goals for patients with acute traumatic SCI were frequently not met in the ICU setting.4,7 Because early surgical intervention may be indicated for patients with traumatic SCI and given the deleterious outcomes associated with systemic hypotension, there is value in determining how often the target MAP is not maintained in the operating room (OR). To date, there are no reliable studies that directly investigate intraoperative blood pressure measurements in acute traumatic SCI.

Our objective was to identify the incidence of hypotension in the OR among patients with acute traumatic SCI and to determine if any associated factors had an impact on those blood pressure measurements. Based on current literature pertaining to the ICU and our anecdotal experiences with this patient population in the OR, we hypothesized that there would be at least a single MAP recording less than the target recommendation of 85 mm Hg for more than half of the spinal decompression and/or stabilization cases performed for patients with acute traumatic SCI at our institution.

Methods

This single-institution, retrospective review was conducted at a level 1 trauma center from February 2015 to December 2016. The institutional review board approved this study and patient consent was waived given its retrospective nature. Our institutional guidelines for all trauma patients with an acute SCI included an MAP protocol reflecting the 2013 AANS/CNS guidelines. The protocol recommended placement of an arterial line on admission for blood pressure monitoring and MAP maintenance ≥ 85 mm Hg for a minimum of 96 hours, unless otherwise indicated by the neurosurgery or trauma/critical care team. The arterial line was used for MAP monitoring both inside and outside of the OR. Using TraumaBase software (Clinical Data Management), we identified all patients with acute traumatic SCI anywhere from vertebral level C1 to L1 with ASIA scores ranging from A to D, who underwent spinal instrumentation and/or laminectomy decompression. Those excluded were patients who were pregnant, < 16 years of age, or had died prior to surgery. Additional study variables that are not reportable from the trauma database were obtained from the electronic medical records. These variables included patient demographics, length of hospital stay, length of ICU stay, hospital day of surgery, and intraoperative data including minute-by-minute MAP values. These values were manually extracted into an Excel database (2013; Microsoft Corp.).

Simple comparisons of continuous variables between independent groups were made using 2-sided, 2-sample t-tests. For ordinal variables, simple comparisons used Wilcoxon 2-sample tests. Categorical or dichotomous variables were compared between independent groups using chi-square tests. Models that control for relevant covariates were based on logistic regression for dichotomous outcomes and ANCOVA for continuous outcomes. When sample estimates (e.g., incidence of MAP < 85 mm Hg) were presented, 95% CIs were constructed around each point estimate. Descriptive statistics were reported as the mean ± SD for continuous variables, and as frequencies with percentages for categorical or dichotomous variables. A p value < 0.05 was considered statistically significant.

Results

A total of 33 operative events among 32 patients was identified that met inclusion criteria. All patients underwent surgery within 96 hours of primary injury. This consisted of 22 men and 10 women with ages ranging from 18 to 87 years, with a mean age of 59.03 ± 18.35 years. The average body mass index (BMI) was 28.30 ± 7.10 kg/m2. Mechanisms of injury (MOIs) included 16 motor vehicle collisions/motorcycle collisions (MVCs/MCs), 15 falls, and 1 bicycle accident. The average Injury Severity Score (ISS) was 24.79 ± 9.17. There were 25 cervical and 8 thoracic injuries, of which 10 were ASIA score A, 8 were ASIA score B, 4 were ASIA score C, and 11 were ASIA score D (Table 1). There were no lumbar injuries. MAP monitoring was performed via radial and femoral arterial lines (97% vs 3%, respectively). One patient required a femoral arterial line due to bilateral forearm fractures. Laterality of the arterial lines was also analyzed, demonstrating a greater number of right-sided lines compared to left-sided lines (64% vs 36%, respectively).

TABLE 1.

Demographic data in 32 patients with SCI

CharacteristicValue
No. of patients32
No. of operative interventions*33
Average age ± SD, yrs59.03 ± 18.35
Sex
 Male68.75%
 Female31.25%
Average BMI ± SD, kg/m228.30 ± 7.10
Average ISS ± SD24.79 ± 9.17
MOI
 Fall46.88%
 MVC/MC50.00%
 Bicycle accident0.03%
ASIA score
 A30.30%
 B24.24%
 C12.12%
 D33.33%
Location of injury
 Cervical75.76%
 Thoracic24.24%

One patient required 2 operative interventions for their SCI during their hospital stay.

All 33 cases had at least one intraoperative MAP reading < 85 mm Hg. These hypotensive episodes lasted, on average, 103 cumulative minutes per operative case. Thirty-two cases (97%) had at least one MAP reading < 75 mm Hg, lasting an average of 41 cumulative minutes per case. Twenty-four cases (73%) had at least one MAP reading < 65 mm Hg, lasting an average of 11 cumulative minutes per case (Fig. 1). Relative to total OR time, the average cumulative time spent with MAP recordings < 85 mm Hg, 75 mm Hg, and 65 mm Hg were 52%, 22%, and 7%, respectively (Fig. 2). Results were further stratified by cervical and thoracic SCI (Fig. 3).

FIG. 1.
FIG. 1.

Bar graph demonstrating the average cumulative time spent in an MAP range. Thirty-two patients underwent a total of 33 operative interventions.

FIG. 2.
FIG. 2.

Pie chart showing the cumulative duration of MAP ranges relative to total OR time.

FIG. 3.
FIG. 3.

Bar graph demonstrating the average time patients experienced an intraoperative MAP less than the target value, based on region of the SCI.

Patients who suffered from a fall were significantly more likely to have an intraoperative MAP ≤ 85 mm Hg compared to those with MVCs/MCs (61% vs 42%; p = 0.033). Subgroup analysis comparing falls to MVCs/MCs demonstrated no statistically significant difference when comparing the attending neurosurgeon; estimated blood loss; type and amount of blood product transfusion (packed red blood cells, fresh-frozen plasma, platelets, or cryoprecipitate); or type and volume of intravenous fluid used (normal saline, lactated Ringers, or albumin). For the patient who suffered a bicycle injury, they spent 53.3% of their total OR time under the MAP target. There were no significant differences in frequency of MAP recordings < 85 mm Hg when analyzed according to age (p = 0.65), sex (p = 0.58), BMI (p = 0.35), ISS (p = 0.36), level of SCI (48% vs 64% for cervical vs thoracic, respectively; p = 0.08), or ASIA score (p = 0.34) (Table 2).

TABLE 2.

Below target MAP and associated factors

FactorNo. of PtsMean % MAP<85 mm Hg, ± SDp Value
Mechanism of injury
 MVC/MC1742 ± 24%0.033
 Fall1561 ± 17%
Level of SCI
 Cervical2548 ± 25%0.08
 Thoracic864 ± 30%
ASIA score
 A1048 ± 26%0.34
 B848 ± 26%
 C472 ± 18%
 D1151 ± 19%
Hospital day of surgery
 1649 ± 27%0.85
 21150 ± 19%
 ≥31654 ± 25%
Laminectomy
 No566 ± 30%0.18
 Yes1849 ± 22%
Use of spinal fixation hardware
 No450 ± 26%0.83
 Yes2952 ± 23%
Surgical positioning
 Prone2253 ± 25%0.76
 Supine1050 ± 21%
Use of blood product transfusion
 No2753 ± 23%0.49
 Yes646 ± 25%

Pts = patients.

Boldface type indicates statistical significance.

Other perioperative variables demonstrated no statistically significant effect on intraoperative MAP measurements < 85 mm Hg. This included hospital day of surgery (day 1, 49%; day 2, 50%; day ≥ 3, 54%; p = 0.85); length of surgery; total OR time; need for laminectomy decompression (p = 0.18); use of spinal fixation hardware; surgical positioning (prone vs supine); intraoperative blood loss (p = 0.16); or use of blood product transfusion. Furthermore, there was no statistically significant effect of MAP recordings less than the target value and length of hospital stay (p = 0.12), length of stay in the ICU, or discharge disposition. There was one death in this study, and that patient experienced an MAP < 85 mm Hg for 53.3% of their total operative time.

Discussion

Our study identified that episodes of relative intraoperative hypotension (MAP ≤ 85 mm Hg) occurred 51.9% of the total OR time. This is a much higher proportion than previously reported in an ICU setting, where hypotension only occurred 18.4% of the time for cervical SCI and 35.9% of the time for thoracic SCI during a 3- to 5-day period postinjury.7 In another study in which MAP values for patients with acute SCI were monitored in the ICU for 7 days, 29.8% of measurements fell below the recommended target value of 85 mm Hg.4 Additionally, Tee et al. reported that in patients with acute traumatic SCI in the early, postinjury, prehospital setting, 52% of their MAP measurements were < 80 mm Hg.15 Furthermore, 100% of the patients in our study experienced at least one MAP reading < 85 mm Hg, which was far greater than the expectation of 50% that we hypothesized. Our findings demonstrated poor intraoperative MAP maintenance at the minimum recommended levels in acute traumatic SCIs.

It is well documented in the literature that secondary cord injury, and the severity of that injury, is associated with the degree of cord hypoperfusion. Animal models have demonstrated that direct cord compression causes neuronal ischemia from diminished cord perfusion, which promotes further secondary insult to the parenchyma.10 Another study showed that diminished response in electrophysiological monitoring, presumably caused by iatrogenic cord injuries, was restored back to baseline following blood pressure improvement.12 Additionally, a study of patients with SCI in the ICU determined that aggressive fluid resuscitation and blood pressure augmentation to a goal of > 85 mm Hg led to improved neurological outcomes in both complete and incomplete SCI at 6- and 12-month follow-up.16 So, the present study detailing systemic hypotension in the OR provides tremendous value that may impact neurological outcomes in patients with acute traumatic SCI who require operative intervention.

Recent studies have questioned if MAP is the most optimal marker to assess whether the spinal cord is being sufficiently perfused. Squair et al. described a study of patients with SCI who were monitored with intrathecal pressure (ITP) and MAP monitoring.13 They reported that MAP is a poor predictor of neurological recovery. However, these authors stated that calculating the spinal cord perfusion pressure (SCPP) and maintaining that pressure > 50 mm Hg was a more accurate marker for improved neurological outcomes. Additionally, Kwon et al. described a study in which SCI patients were monitored for ITP and MAP, and noted that the ITP increased immediately following operative decompression, which led to a decrease in SCPP, assuming a constant MAP.8 Therefore, it is possible that patients are not receiving adequate perfusion to their spinal cord after decompression, despite having an MAP that is at or above goal. The ITP was not routinely measured in the present study, so we cannot comment on this relationship as it pertains to intraoperative hypotension and neurological outcomes. However, without an adequate systemic MAP, the spinal cord will not be sufficiently perfused, regardless of the ITP. Therefore, intraoperative hypotension, as quantified in the present study, is a problem that needs to be addressed, but future studies should also include ITP and SCPP measurements to help guide clinicians on how to best manage patients with acute traumatic SCI.

In the present study, we focused solely on the incidence of relative hypotension in the OR and investigated if any associated variables put our patients at higher risk. Besides a statistically significant increase in the frequency of intraoperative hypotension associated with fall MOIs, we failed to identify any other significant factor that put our patients at increased risk. To explain this finding, we analyzed the data to determine if there were any significant differences between the 2 cohorts. We found that the patients with fall MOIs had a statistically significant decrease in length of hospital stay (p = 0.007) and length of ICU stay (p = 0.004), but there was a significantly higher number of patients with use of prehospital blood thinners (p = 0.036). This higher use of blood thinners in the fall cohort may explain the increased relative hypotension, due to the increased risk of hemorrhage. However, there was no significant difference in estimated intraoperative blood loss (p = 0.928) or use of blood product transfusion (p = 0.522), so we cannot attribute the difference in relative hypotension to blood loss. Furthermore, we would have expected that patients with significantly greater proportions of relative intraoperative hypotension would have required extended ICU and hospital stays, given the increased risk of secondary cord injury. However, our results demonstrated the opposite; the MVC/MC cohort had significantly longer ICU and hospital stays compared to the fall cohort.

Other factors analyzed showed no statistically significant differences between the 2 cohorts. This included average ISS (p = 0.0534), polytrauma (p = 0.157), thoracic cord injuries (p = 0.124), BMI (p = 0.549), ASIA score (p = 0.191), and hospital day of surgery. We also considered the impact of comorbidities, so we noted if patients had hypertension, coronary artery disease, cerebrovascular disease, diabetes mellitus, hyperlipidemia, peripheral vascular disease, chronic obstructive pulmonary disease, chronic kidney disease, or coagulopathy and found that patients with fall MOIs had no significant difference in average total number of comorbidities compared to patients with MVC/MC MOIs (1.73 vs 0.81, respectively; p = 0.250). Both fall and MVC/MC cohorts had similar distributions of individual comorbidities, except for coronary artery disease (26.7% vs 0.0%, respectively). After examining these 2 groups, we were unable to elucidate a clear explanation for the difference in relative intraoperative hypotension that exists between patients with fall and MVC/MC MOIs in this study. With a larger sample size, we may identify a particular factor that puts patients at risk of developing intraoperative hypotension based on MOI—however, it is likely that many factors are responsible for this finding. Furthermore, with our study population being relatively small, the generalizability of our finding that fall MOIs lead to increased relative hypotension may be limited.

Given that there are no other studies that describe the incidence of intraoperative hypotension in this patient population, we compared this finding to the literature that reported results for patients with traumatic SCIs strictly in the ICU setting. Unfortunately, these studies did not report MOI data, but they did observe significant proportions of MAP measurements below their targeted thresholds.4,7 Hawryluk et al. found that 24.9% of all MAP measures below their target value of 85 mm Hg occurred during the first 5 days after injury.4 Associating this with their measured outcome data, they concluded that average MAP values above their target threshold were most significant for the first 2–3 days after injury. Kong et al. reported a series of 21 patients, with all patients having at least one MAP recording below the target value of 80 mm Hg and a mean MAP of 83.7 mm Hg.7 In their study, the cumulative frequency of MAP recordings less than the target value was higher among patients with thoracic SCIs compared to cervical SCIs, a finding that was identical to our study. The frequency of MAP below the target value in both cohorts was higher in our study population (thoracic 35.9% vs 64.0%; cervical 18.4% vs 48.0%); however, their MAP goal was 80 mm Hg compared to ours of 85 mm Hg. Kong et al. also found that individuals with ASIA score A injuries, characterized as a complete SCI with no motor or sensory functionality, were more likely to experience MAP below the target value. This was different from our study, in which there was no significant difference in intraoperative hypotension associated with ASIA score.

The incidence of hypotension in acute SCI was higher in the OR among our trauma population compared to the ICU in other studies. Hypotension can occur more frequently in the OR for several potential reasons. For example, our patients were subjected to anesthetics and were at increased risk of blood loss due to surgical intervention. If a patient experienced major blood loss in the OR leading to hemorrhagic shock, the clinical team may have used permissive hypotension.5 These potential explanations for the difference in incidence of systemic hypotension between the 2 settings are limited, because it was not the intention of our study to provide a reason for this disparity.

Given that our institutional MAP protocol was based on the AANS/CNS guidelines, it is important to acknowledge that exceptions to the protocol exist in certain situations. Because the incidence of intraoperative hypotension was greater than we initially predicted, it is necessary to explore these exceptions, as they may have contributed to this finding. For example, the use of vasopressors or aggressive fluid resuscitation may precipitate severe adverse reactions, such as acute respiratory distress syndrome, multiple organ failure, arrhythmias, or skin necrosis.2,6 It may be that the clinical team augmented the MAP protocol secondary to this perceived risk. However, our study did not monitor patients for long-term sequelae resulting from failure to maintain the > 85 mm Hg MAP protocol. Vale et al. monitored a similar patient population for an average of 17 months after they received aggressive fluid resuscitation and/or blood pressure augmentation therapy to a goal MAP of > 85 mm Hg and found no instances of long-term adverse events, such as hypertensive hemorrhage, stroke, myocardial infarction, or death.16

Limitations of this study include the small sample size, single institution, retrospective design, and lack of long-term follow-up for clinical outcomes. A multiinstitutional study with a larger cohort would aid in generalizing these results and probably help determine relevance in such associated factors as MOI, thoracic versus cervical cord injuries, preoperative ASIA score, and use of laminectomy. Furthermore, a prospective study with long-term follow-up to assess the neurological impact of intraoperative hypotension would provide meaningful results that may dictate how strictly intraoperative MAP will be maintained in the future. Given our retrospective review, we were unable to verify the quality of the arterial line waveforms; this quality control should be included in future prospective studies. Despite these limitations, our findings are substantial given the frequency of occurrence and potential for detrimental clinical outcomes with hypotension in patients with acute SCI.

Conclusions

To our knowledge, this is the first study quantifying the incidence of intraoperative hypotension for neurosurgical repair of vertebral injuries in acute traumatic SCI. Not only did 100% of our patients with acute traumatic SCI register at least one relative hypotensive MAP reading in the OR, but the relative hypotension occurred 51.9% of the total OR time. Future studies should investigate the predictive nature of intraoperative hypotension and if there are critical times during the operative course in which relative hypotension occurs more frequently. This information could influence the management and anesthetic plan for these patients, so the clinical team can proactively treat to avoid systemic hypotension. With current literature demonstrating the importance of maintaining MAP during the initial days of SCI, this study raises awareness among surgeons and anesthesiologists, which may ultimately improve neurological outcomes.

Acknowledgments

We acknowledge Josh Burton, RN, MSN, for his project management and Mike Lieber, MS, for performing statistical analysis.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Gaudin, Spalding, Narayan. Acquisition of data: Gaudin, Pugh. Analysis and interpretation of data: all authors. Drafting the article: Gaudin, Wochna, Wolff, Pugh, Spalding. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Gaudin. Statistical analysis: Gaudin, Wochna, Wolff. Study supervision: Gaudin, Spalding, Narayan.

Supplemental Information

Previous Presentations

The abstract was presented at the 2017 Annual Clinical Assembly of Osteopathic Surgeons in National Harbor, Maryland.

References

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  • Collapse
  • Expand

Figure from Lau et al. (pp 23–30).

  • FIG. 1.

    Bar graph demonstrating the average cumulative time spent in an MAP range. Thirty-two patients underwent a total of 33 operative interventions.

  • FIG. 2.

    Pie chart showing the cumulative duration of MAP ranges relative to total OR time.

  • FIG. 3.

    Bar graph demonstrating the average time patients experienced an intraoperative MAP less than the target value, based on region of the SCI.

  • 1

    Catapano JS, Hawryluk GWJ, Whetstone W, Saigal R, Ferguson A, Talbott J, et al.: Higher mean arterial pressure values correlate with neurological improvement in patients with initially complete spinal cord injuries. World Neurosurg 96:7279, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    De Backer D, Biston P, Devriendt J, Madl C, Chochrad D, Aldecoa C, et al.: Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med 362:779789, 2010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Devivo MJ: Epidemiology of traumatic spinal cord injury: trends and future implications. Spinal Cord 50:365372, 2012

  • 4

    Hawryluk G, Whetstone W, Saigal R, Ferguson A, Talbott J, Bresnahan J, et al.: Mean arterial blood pressure correlates with neurological recovery after human spinal cord injury: analysis of high frequency physiologic data. J Neurotrauma 32:19581967, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

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