Early Blood Pressure Targets in Acute Spinal Cord Injury: A Randomized Clinical Trial

1. Early augmented blood pressure management did not result in better neurological recovery compared with conventional blood pressure management at 6 months in patients with spinal cord injury.

Evidence Rating Level: 2 (Good)

Although spinal cord injury (SCI) guidelines recommend maintaining higher than normal mean arterial pressure (MAP) for 3-7 days post-injury, they are based on low-quality evidence of neurologic improvement. The impact of early targeted hemodynamic management on long-term neurological outcomes after SCI has not been systematically studied. This study thus compared the efficacy and safety of early blood pressure augmentation vs conventional blood pressure on neurological outcomes after acute SCI. This randomized clinical trial was conducted at 13 large US trauma centers from October 3, 2017, to July 26, 2023, and included patients >18 years with SCI followed up for 6 months. Patients were randomized 1:1 to two groups: augmented blood pressure group (ABP) (target MAP >85-90 mm Hg) or conventional blood pressure (CBP) (target MAP >65-70 mm Hg), with MAP targets maintained for 7 days or until intensive care unit discharge. Primary end points were motor and sensory changes from baseline to 6 months based on scores from the American Spinal Injury Association Impairment Scale. A total of 92 patients were included in this study (mean [SD] age, 53.78 [18.74] years; 76 [83%] male). At 6 months, 38 patients completed follow-up, and 15 had died. Among survivors, there were no mean (SD) differences observed between ABP and CBP groups for change from baseline in upper extremity motor scores (34.95 [3.25] vs 32.95 [3.65]; difference, 2.48; 95% CI, −5.93 to 10.90), lower extremity motor scores (18.53 [4.62] vs 19.95 [4.59]; difference, −4.56; 95% CI, −16.11 to 7.03), or total sensory scores (108.47 [12.49] vs 130.89 [14.87]; difference, −32.00; 95% CI, −65.40 to 1.40). Compared to the CBP group, the ABP group had higher mean (SD) modified Sequential Organ Failure Assessment scores (excluding cardiovascular components) at day 3 (1.65 [1.79] vs 0.80 [1.10]; difference, 0.85; 95% CI, 0.23-1.47) and day 6 (1.55 [1.82] vs 0.80 [1.35]; difference, 0.74; 95% CI, 0.05-1.44), longer mechanical ventilatory support (9.44 [15.27] vs 3.78 [8.42] days; difference, 5.67 days; 95% CI, 0.48-10.85 days), and more respiratory complications (36 [78%] vs 18 [39%]; risk difference, 40%; 95% CI, 22%-58%). There were no differences observed in mortality or other secondary outcomes. Overall, early augmented blood pressure management did not result in better neurological recovery compared with conventional blood pressure management at 6 months in patients with SCI. These findings call into question the practice of MAP augmentation in this population. However, as this study was underpowered, future studies with larger sample sizes are needed to validate these results.

Click to read this study in JAMA Network Open

Image: PD

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