Vasopressor support in managing acute spinal cord injury: current knowledge.

INTRODUCTION: Managing neurogenic shock following acute traumatic spinal cord injury (SCI) is challenging. Current guidelines target mean arterial pressure (MAP) above 85-90 mmHg to maintain cord perfusion and reduce ischemia/secondary injury. While early vasopressor utilization has been associated with improved outcomes, recent updates regarding indications of specific vasopressors for refinement of existing guidelines are needed.

EVIDENCE ACQUISITION: A comprehensive search was conducted using the National Library of Medicine PubMed database between 01/2010 and 01/2017 targeting vasopressor use in the setting of neurogenic/spinal shock and/or hypotension following acute SCI in adult patients. Special focus was provided for endpoints of comparative advantage, complications, and adjunctive agents.

EVIDENCE SYNTHESIS: Seven reports met inclusion criteria. In complete and incomplete SCI, rates of vasopressor-associated complications were greater for dopamine compared to phenylephrine. Norepinephrine provided a comparative 2-mmHg increase to spinal cord perfusion pressure without differential MAP effects versus dopamine. In elderly SCI, more vasopressor and dopamine-specific complications were observed. A case series found adjunct oral pseudoephedrine to be successful in wean off intravenous vasopressors. One study of various MAP thresholds 65-90 mmHg found no correlations with neurological outcome.

CONCLUSIONS: Class III evidence has been augmented regarding vasopressor usage following acute SCI, however comparative benefits between vasopressors remain in need of elucidation due to small sample sizes and/or inadequate specificity to spine injury levels. Large prospective multicenter studies targeting age cohorts, and characterizing associated comorbidities and complication profiles, are of high priority in order to determine judicious use criteria of specific vasopressors for relevant subpopulations.