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Zeller SL, Stein A, Frid I, Carpenter AB, Soldozy S, Rawanduzy C, Rosenberg J, Bauerschmidt A, Al-Mufti F, Mayer SA, Kinon MD, Wainwright JV. Critical Care of Spinal Cord Injury. Curr Neurol Neurosci Rep 2024:10.1007/s11910-024-01357-8. [PMID: 39008022 DOI: 10.1007/s11910-024-01357-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2024] [Indexed: 07/16/2024]
Abstract
PURPOSE OF REVIEW Spinal cord injury (SCI) is a major cause of morbidity and mortality, posing a significant financial burden on patients and the healthcare system. While little can be done to reverse the primary mechanical insult, minimizing secondary injury due to ischemia and inflammation and avoiding complications that adversely affect neurologic outcome represent major goals of management. This article reviews important considerations in the acute critical care management of SCI to improve outcomes. RECENT FINDINGS Neuroprotective agents, such as riluzole, may allow for improved neurologic recovery but require further investigation at this time. Various forms of neuromodulation, such as transcranial magnetic stimulation, are currently under investigation. Early decompression and stabilization of SCI is recommended within 24 h of injury when indicated. Spinal cord perfusion may be optimized with a mean arterial pressure goal from a lower limit of 75-80 to an upper limit of 90-95 mmHg for 3-7 days after injury. The use of corticosteroids remains controversial; however, initiation of a 24-h infusion of methylprednisolone 5.4 mg/kg/hour within 8 h of injury has been found to improve motor scores. Attentive pulmonary and urologic care along with early mobilization can reduce in-hospital complications.
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Affiliation(s)
- Sabrina L Zeller
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
- Department of Neurosurgery, New York Medical College, Valhalla, NY, USA
| | - Alan Stein
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
- Department of Neurosurgery, New York Medical College, Valhalla, NY, USA
| | - Ilya Frid
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
- Department of Neurosurgery, New York Medical College, Valhalla, NY, USA
| | - Austin B Carpenter
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
- Department of Neurosurgery, New York Medical College, Valhalla, NY, USA
| | - Sauson Soldozy
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
- Department of Neurosurgery, New York Medical College, Valhalla, NY, USA
| | - Cameron Rawanduzy
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
- Department of Neurosurgery, New York Medical College, Valhalla, NY, USA
| | - Jon Rosenberg
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
- Department of Neurosurgery, New York Medical College, Valhalla, NY, USA
| | - Andrew Bauerschmidt
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
- Department of Neurosurgery, New York Medical College, Valhalla, NY, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
- Department of Neurosurgery, New York Medical College, Valhalla, NY, USA
| | - Stephan A Mayer
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
- Department of Neurosurgery, New York Medical College, Valhalla, NY, USA
| | - Merritt D Kinon
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
- Department of Neurosurgery, New York Medical College, Valhalla, NY, USA
- Department of Orthopedic Surgery, New York Medical College, 100 Woods Road, Valhalla, NY, 10595, USA
| | - John V Wainwright
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA.
- Department of Neurosurgery, New York Medical College, Valhalla, NY, USA.
- Department of Orthopedic Surgery, New York Medical College, 100 Woods Road, Valhalla, NY, 10595, USA.
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Jensen VN, Huffman EE, Jalufka FL, Pritchard AL, Baumgartner S, Walling I, C. Gibbs H, McCreedy DA, Alilain WJ, Crone SA. V2a neurons restore diaphragm function in mice following spinal cord injury. Proc Natl Acad Sci U S A 2024; 121:e2313594121. [PMID: 38442182 PMCID: PMC10945804 DOI: 10.1073/pnas.2313594121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 01/15/2024] [Indexed: 03/07/2024] Open
Abstract
The specific roles that different types of neurons play in recovery from injury is poorly understood. Here, we show that increasing the excitability of ipsilaterally projecting, excitatory V2a neurons using designer receptors exclusively activated by designer drugs (DREADDs) restores rhythmic bursting activity to a previously paralyzed diaphragm within hours, days, or weeks following a C2 hemisection injury. Further, decreasing the excitability of V2a neurons impairs tonic diaphragm activity after injury as well as activation of inspiratory activity by chemosensory stimulation, but does not impact breathing at rest in healthy animals. By examining the patterns of muscle activity produced by modulating the excitability of V2a neurons, we provide evidence that V2a neurons supply tonic drive to phrenic circuits rather than increase rhythmic inspiratory drive at the level of the brainstem. Our results demonstrate that the V2a class of neurons contribute to recovery of respiratory function following injury. We propose that altering V2a excitability is a potential strategy to prevent respiratory motor failure and promote recovery of breathing following spinal cord injury.
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Affiliation(s)
- Victoria N. Jensen
- Neuroscience Graduate Program, University of Cincinnati College of Medicine, Cincinnati, OH45219
| | - Emily E. Huffman
- Department of Neuroscience, University of Kentucky College of Medicine, Lexington, KY40536
- Spinal Cord and Brain Injury Research Center, University of Kentucky College of Medicine, Lexington, KY40536
| | - Frank L. Jalufka
- Department of Biology, Texas A&M University, College Station, TX77843
| | - Anna L. Pritchard
- Department of Biomedical Engineering, Texas A&M University, College Station, TX77843
| | - Sarah Baumgartner
- Division of Neurosurgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH45229
| | - Ian Walling
- Neuroscience Graduate Program, University of Cincinnati College of Medicine, Cincinnati, OH45219
- Medical Scientist Training Program, University of Cincinnati College of Medicine, Cincinnati, OH45267
| | - Holly C. Gibbs
- Department of Biomedical Engineering, Texas A&M University, College Station, TX77843
- Microscopy and Imaging Center, Texas A&M University, College Station, TX77843
| | - Dylan A. McCreedy
- Department of Biology, Texas A&M University, College Station, TX77843
- Department of Biomedical Engineering, Texas A&M University, College Station, TX77843
- Texas A&M Institute for Neuroscience, Texas A&M University, College Station, TX77843
| | - Warren J. Alilain
- Department of Neuroscience, University of Kentucky College of Medicine, Lexington, KY40536
- Spinal Cord and Brain Injury Research Center, University of Kentucky College of Medicine, Lexington, KY40536
| | - Steven A. Crone
- Division of Neurosurgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH45229
- Division of Developmental Biology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH45229
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH45267
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Eriks-Hoogland IE, Barth MA, Müller LL, Braun D, Curt A, Arora M, Middleton JW, Pannek J. COVID-19 and spinal cord injury: clinical presentation, clinical course, and clinical outcomes of people hospitalised. Spinal Cord Ser Cases 2024; 10:5. [PMID: 38351025 PMCID: PMC10864293 DOI: 10.1038/s41394-024-00617-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 02/16/2024] Open
Abstract
STUDY DESIGN Retrospective study OBJECTIVES: To describe the presenting symptoms/signs, clinical course and outcomes in hospitalised people with spinal cord injury (SCI) and symptomatic COVID-19 infections. SETTING One university hospital and two SCI centres in Switzerland. METHODS Descriptive analysis of symptoms/signs, clinical course and outcomes of people with SCI with symptomatic COVID-19 infections and need for hospitalisation. RESULTS Twenty-two people with SCI were included, 15 (68%) were male, median age 64.5 years (interquartile range, IQR, 52-73 years). Nine (41%) had tetraplegia, and eight (36%) were classified with motor-complete lesions. Frequent clinical symptoms were fever (59%), coughing (54%), fatigue (50%), and dyspnoea (27%). Most frequent complications were bacterial pulmonary superinfection (18%), and acute respiratory distress syndrome (18%). Fifteen persons (68%) needed oxygen therapy during the course of hospitalisation, and 7 (32%) people were ventilated. Median length of stay (LOS) was 23 days (IQR 15-35), varying by age for people under 60 years with a median LOS of 9 days (IQR 8-27), and for those older than 60 years with a median of 34 days (IQR 17-39), respectively. In total, 3 persons (14%) died during hospitalisation, all older with paraplegia. CONCLUSIONS Typical symptoms like fever and coughing were not present in all people. People with tetraplegia did not demonstrate worse outcomes, on the contrary, they had shorter LOS, no difference in ventilation needs, and no higher mortality compared to people with paraplegia. Older people showed longer LOS. This study recommends close supervision of the SCI population to detect early signs and symptoms of COVID-19 infection.
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Affiliation(s)
- Inge E Eriks-Hoogland
- Swiss Paraplegic Centre, Nottwil, Switzerland.
- Faculty of Health Sciences and Medicine at the University of Lucerne, Lucerne, Switzerland.
- Swiss Paraplegic Research, Nottwil, Switzerland.
| | | | | | - Dominique Braun
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Mohit Arora
- John Walsh Centre for Rehabilitation Research, Northern Sydney Local Health District, St Leonards, NSW, Australia
- The Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - James W Middleton
- John Walsh Centre for Rehabilitation Research, Northern Sydney Local Health District, St Leonards, NSW, Australia
- The Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Jürgen Pannek
- Swiss Paraplegic Centre, Nottwil, Switzerland
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Zhang R, Xu X, Chen H, Beck J, Sinderby C, Qiu H, Yang Y, Liu L. Predicting extubation in patients with traumatic cervical spinal cord injury using the diaphragm electrical activity during a single maximal maneuver. Ann Intensive Care 2023; 13:122. [PMID: 38055103 DOI: 10.1186/s13613-023-01217-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 11/20/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND The unsuccessful extubation in patients with traumatic cervical spinal cord injuries (CSCI) may result from impairment diaphragm function and monitoring of diaphragm electrical activity (EAdi) can be informative in guiding extubation. We aimed to evaluate whether the change of EAdi during a single maximal maneuver can predict extubation outcomes in CSCI patients. METHODS This is a retrospective study of CSCI patients requiring mechanical ventilation in the ICU of a tertiary hospital. A single maximal maneuver was performed by asking each patient to inhale with maximum strength during the first spontaneous breathing trial (SBT). The baseline (during SBT before maximal maneuver), maximum (during the single maximal maneuver), and the increase of EAdi (ΔEAdi, equal to the difference between baseline and maximal) were measured. The primary outcome was extubation success, defined as no reintubation after the first extubation and no tracheostomy before any extubation during the ICU stay. RESULTS Among 107 patients enrolled, 50 (46.7%) were extubated successfully at the first SBT. Baseline EAdi, maximum EAdi, and ΔEAdi were significantly higher, and the rapid shallow breathing index was lower in patients who were extubated successfully than in those who failed. By multivariable logistic analysis, ΔEAdi was independently associated with successful extubation (OR 2.03, 95% CI 1.52-3.17). ΔEAdi demonstrated high diagnostic accuracy in predicting extubation success with an AUROC 0.978 (95% CI 0.941-0.995), and the cut-off value was 7.0 μV. CONCLUSIONS The increase of EAdi from baseline SBT during a single maximal maneuver is associated with successful extubation and can help guide extubation in CSCI patients.
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Affiliation(s)
- Rui Zhang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine,, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Xiaoting Xu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine,, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Hui Chen
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine,, Southeast University, Nanjing, 210009, Jiangsu, China
- Department of Critical Care Medicine, The First Affiliated Hospital of Soochow University, Soochow University, No. 899 Pinghai Road, Suzhou, 215000, People's Republic of China
| | - Jennifer Beck
- Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Department of Critical Care, St. Michael's Hospital, Toronto, Canada
- Department of Pediatrics, University of Toronto, Toronto, Canada
- Member, Institute for Biomedical Engineering and Science Technology (iBEST) at Ryerson University and St-Michael's Hospital, Toronto, Canada
| | - Christer Sinderby
- Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Department of Critical Care, St. Michael's Hospital, Toronto, Canada
- Member, Institute for Biomedical Engineering and Science Technology (iBEST) at Ryerson University and St-Michael's Hospital, Toronto, Canada
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine,, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine,, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Ling Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine,, Southeast University, Nanjing, 210009, Jiangsu, China.
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Lv Q, Zhang X, Guo K, Hu D, Deng Z. Risk Factors for Pulmonary Infection and Nursing Interventions Post-Tracheostomy in Patients with Spinal Cord Injury. Infect Drug Resist 2023; 16:6691-6701. [PMID: 37854469 PMCID: PMC10581007 DOI: 10.2147/idr.s418894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 09/21/2023] [Indexed: 10/20/2023] Open
Abstract
Objective We analyzed the characteristics and risk factors for pulmonary infection in patients with spinal cord injury who underwent tracheostomy and propose measures to help in early detection and intervention to reduce mortality and improve prognosis. Methods We collected data retrospectively from January 1, 2018, to December 31, 2022. The inclusion criteria were: Patients aged 18 years or more with a spinal cord injury who underwent tracheostomy, were treated with mechanical ventilation for over 48 hours, and were diagnosed as having a pulmonary infection. Sputum samples were cultured and analyzed. Results 101 cases of pulmonary infection were analyzed, and the incidence was 32.17%. Diabetes (OR 2.302, 95% CI 1.285-3.972), hypoproteinemia (OR 1.992, 95% CI 1.125-3.101), administration of glucocorticoids (OR 2.934, 95% CI 1.412-4.661), ASIA grade A (OR 3.672, 95% CI 1.988-5.046), mechanical ventilation for ≥ 6 days (OR 2.108, 95% CI 1.385-4.751), and length of hospital stay for ≥ 20 days (OR 2.137, 95% CI 1.092-3.842) were risk factors for pulmonary infection in patients with spinal cord injury post-tracheostomy. Among 213 pathogenic bacteria, 52 (51.48%) were Gram-negative and 24 (23.76%) were Gram-positive. Klebsiella pneumoniae (15.84%) and Staphylococcus aureus (8.91%) were the most common pathogenic bacteria. The mortality rate of patients with gram-positive infection was higher than that of patients with gram-negative infection. K. pneumoniae and S. aureus were sensitive to cefoperazone, meropenem, and levofloxacin. Conclusion Pulmonary infection is a complication post-tracheostomy in patients with spinal cord injury. Diabetes, hypoproteinemia, administration of glucocorticoids, mechanical ventilation for ≥ 6 days, length of hospital stay for ≥ 20 days were risk factors for pulmonary infection. Pulmonary infection was mainly caused by gram-negative bacteria. Timely and effective measures for managing risk factors are essential for improving the prognosis of pulmonary infection post-tracheostomy in patients with spinal cord injuries.
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Affiliation(s)
- Qin Lv
- Department of Emergency, The Third Hospital of Hebei Medical University, Shijiazhuang City, Hebei Province, 050051, People’s Republic of China
| | - Xinliang Zhang
- Department of Emergency, The Third Hospital of Hebei Medical University, Shijiazhuang City, Hebei Province, 050051, People’s Republic of China
| | - Kucun Guo
- Department of Emergency, The Third Hospital of Hebei Medical University, Shijiazhuang City, Hebei Province, 050051, People’s Republic of China
| | - Dezheng Hu
- Department of Emergency, The Third Hospital of Hebei Medical University, Shijiazhuang City, Hebei Province, 050051, People’s Republic of China
| | - Zhuojun Deng
- Department of General Medicine, The Third Hospital of Hebei Medical University, Shijiazhuang City, Hebei Province, 050000, People’s Republic of China
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Hyun SE, Hwang W, Ji HM, Shin HI. Effect of body position on peak expiratory flow during mechanical insufflation-exsufflation in people with cervical spinal cord injury: a pilot study. Sci Rep 2023; 13:16548. [PMID: 37783754 PMCID: PMC10545699 DOI: 10.1038/s41598-023-43256-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 09/21/2023] [Indexed: 10/04/2023] Open
Abstract
This prospective pilot study investigated the influence of body position on peak cough flow (PCF) during mechanical insufflation-exsufflation (MI-E) treatment in people with tetraplegia. Fifteen participants with cervical spinal cord injury (C-SCI) were randomized into two groups, which differed in the starting position, that is, the patients were either supine or reclined. Four sessions of MI-E in alternating positions with each session comprising three different maneuvers: five voluntary coughs, five MI-E-assisted coughs, and five MI-E-assisted with manual thrusts were performed with continuous airflow measurement reporting PCF from every cough. PCF was associated with the application maneuvers, total insufflation volume (TIV), and interaction between position and maneuvers but not with the application position. The estimated mean PCF was 1.808, 3.529, and 3.925 L/s when supine and 1.672, 3.598, and 3.909 L/s when reclined from voluntary cough, MI-E, and MI-E with manual thrust, respectively. The estimated PCF change compared to voluntary cough was 1.721 (95% CI, 1.603-1.838) L/s from the combined MI-E and 2.116 (95% CI, 2.005-2.228) L/s from the MI-E with manual thrust, calculated from the linear mixed-model analysis. PCF moderately correlated with TIV (R2 = 0.64). Therefore, either position can be used for C-SCI patients as long as MI-E can be performed with manual thrust and sufficient TIV is provided.
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Affiliation(s)
- Sung Eun Hyun
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Wonjae Hwang
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hye Min Ji
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Veterans Medical Research Institute, Veterans Health Service Medical Center, Seoul, Korea
| | - Hyung-Ik Shin
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul, Republic of Korea.
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Visagan R, Boseta E, Zoumprouli A, Papadopoulos MC, Saadoun S. Spinal cord perfusion pressure correlates with breathing function in patients with acute, cervical traumatic spinal cord injuries: an observational study. Crit Care 2023; 27:362. [PMID: 37730639 PMCID: PMC10512582 DOI: 10.1186/s13054-023-04643-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 09/09/2023] [Indexed: 09/22/2023] Open
Abstract
OBJECTIVE This study aims to determine the relationship between spinal cord perfusion pressure (SCPP) and breathing function in patients with acute cervical traumatic spinal cord injuries. METHODS We included 8 participants without cervical TSCI plus 13 patients with cervical traumatic spinal cord injuries, American Spinal Injury Association Impairment Scale grades A-C. In the TSCI patients, we monitored intraspinal pressure from the injury site for up to a week and computed the SCPP as mean arterial pressure minus intraspinal pressure. Breathing function was quantified by diaphragmatic electromyography using an EDI (electrical activity of the diaphragm) nasogastric tube as well as by ultrasound of the diaphragm and the intercostal muscles performed when sitting at 20°-30°. RESULTS We analysed 106 ultrasound examinations (total 1370 images/videos) and 198 EDI recordings in the patients with cervical traumatic spinal cord injuries. During quiet breathing, low SCPP (< 60 mmHg) was associated with reduced EDI-peak (measure of inspiratory effort) and EDI-min (measure of the tonic activity of the diaphragm), which increased and then plateaued at SCPP 60-100 mmHg. During quiet and deep breathing, the diaphragmatic thickening fraction (force of diaphragmatic contraction) plotted versus SCPP had an inverted-U relationship, with a peak at SCPP 80-90 mmHg. Diaphragmatic excursion (up and down movement of the diaphragm) during quiet breathing did not correlate with SCPP, but diaphragmatic excursion during deep breathing plotted versus SCPP had an inverse-U relationship with a peak at SCPP 80-90 mmHg. The thickening fraction of the intercostal muscles plotted versus SCPP also had inverted-U relationship, with normal intercostal function at SCPP 80-100 mmHg, but failure of the upper and middle intercostals to contract during inspiration (i.e. abdominal breathing) at SCPP < 80 or > 100 mmHg. CONCLUSIONS After acute, cervical traumatic spinal cord injuries, breathing function depends on the SCPP. SCPP 80-90 mmHg correlates with optimum diaphragmatic and intercostal muscle function. Our findings raise the possibility that intervention to maintain SCPP in this range may accelerate ventilator liberation which may reduce stay in the neuro-intensive care unit.
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Affiliation(s)
- Ravindran Visagan
- Academic Neurosurgery Unit, St. George's, University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Ellaine Boseta
- Academic Neurosurgery Unit, St. George's, University of London, Cranmer Terrace, London, SW17 0RE, UK
- Neuro-anaesthesia and Neuro-intensive Care Unit, St. George's Hospital, London, SW17 0QT, UK
| | - Argyro Zoumprouli
- Neuro-anaesthesia and Neuro-intensive Care Unit, St. George's Hospital, London, SW17 0QT, UK
| | - Marios C Papadopoulos
- Academic Neurosurgery Unit, St. George's, University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Samira Saadoun
- Academic Neurosurgery Unit, St. George's, University of London, Cranmer Terrace, London, SW17 0RE, UK.
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Kumar A, Khandelwal A, Jamil S. Ventilatory Strategies in Traumatic Cervical Spinal Cord Injury: Controversies and Current Updates. Asian Spine J 2023; 17:615-619. [PMID: 37614075 PMCID: PMC10460671 DOI: 10.31616/asj.2023.0094] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 07/04/2023] [Indexed: 08/31/2023] Open
Abstract
Ventilatory management of patients with traumatic cervical spinal cord injury (CSCI) is a complex and controversial area of critical care medicine. Despite significant advances in our understanding of the pathophysiology of CSCI and the development of novel interventions, there remains a lack of consensus about the optimal approach to ventilatory management in these patients. Some of the key controversies in CSCI ventilatory management include timing of tracheal intubation, non-invasive ventilation versus invasive ventilation, high versus low tidal volume, and early versus late tracheostomy. The objective of this review is to discuss the existing controversies and provide an insight on the current evidence.
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Affiliation(s)
- Ashutosh Kumar
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), Nagpur, India
| | - Ankur Khandelwal
- Department of Anaesthesiology, Critical Care and Pain Medicine, All India Institute of Medical Sciences (AIIMS), Guwahati, India
| | - Shaista Jamil
- Department of Anaesthesiology and Critical Care, School of Medical Sciences and Research, Sharda University, Greater Noida, India
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Ushiku C, Suda K, Michikawa T, Harmon SM, Komatsu M, Tsuji O, Takahata M, Saito M, Iwasaki N, Minami A. Incidence and Risk Factors for Pneumonia in the Chronic Phase of Cervical Spinal Cord Injury with Complete Motor Paralysis. Spine Surg Relat Res 2023; 7:333-340. [PMID: 37636135 PMCID: PMC10447191 DOI: 10.22603/ssrr.2022-0254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/17/2023] [Indexed: 03/14/2023] Open
Abstract
Introduction Pneumonia is one of the leading causes of acute- and chronic-phase mortality in patients with cervical spinal cord injury (CSCI) with quadriplegia. The risk factors for chronic-phase pneumonia recurrence in CSCI are still unknown. This study aimed to investigate the incidence of pneumonia in the chronic phase after injury and to identify its risk factors. Methods This retrospective clinical observational study included patients with CSCI with American Spinal Injury Association Impairment Scale grades of A or B admitted to our center within 72 h of CSCI injury who started treatment and were available for follow-up for at least 90 days. The patients were assessed for incidences of pneumonia and its associations with clinical characteristics, including risk factors at the time of injury. Patients in whom pneumonia developed within 30 days postadmission and those after 30 days of hospitalization were comparatively examined using univariate and multivariate analyses. Results Pneumonia occurred in 36% of the 69 enrolled patients throughout the study period and in 20% of all patients after 30 days of hospitalization. Multivariate analysis of risk factors for pneumonia showed that atelectasis (adjusted OR [aOR], 95% confidence interval [CI]: 4.9, 1.2-20.0), enteral feeding (aOR [95% CI]: 13.3 [3.0-58.9]), mechanical ventilation (aOR [95% CI]: 4.0 [1.0-15.0]), and tracheotomy (aOR [95% CI]: 14.6 [2.3-94.6]) within 30 days of admission were significantly associated with the occurrence of pneumonia even after 30 days of hospitalization. Conclusions The risk factors for developing pneumonia in the chronic phase were atelectasis, enteral feeding, mechanical ventilation, and tracheotomy within 30 days of hospitalization. This study suggests that treatment of atelectasis, long-term respiratory muscle rehabilitation, and training to improve swallowing function are essential to prevent the recurrence of pneumonia after 30 days of hospitalization.
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Affiliation(s)
- Chikara Ushiku
- Department of Orthopedic Surgery, Hokkaido Spinal Cord Injury Center, Bibai, Japan
- Department of Orthopedic Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Kota Suda
- Department of Orthopedic Surgery, Hokkaido Spinal Cord Injury Center, Bibai, Japan
| | - Takehiro Michikawa
- Department of Environmental and Occupational Health, School of Medicine, Toho University, Tokyo, Japan
| | | | - Miki Komatsu
- Department of Orthopedic Surgery, Hokkaido Spinal Cord Injury Center, Bibai, Japan
| | - Osahiko Tsuji
- Department of Orthopedic Surgery, Hokkaido Spinal Cord Injury Center, Bibai, Japan
| | - Masahiko Takahata
- Department of Orthopedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Mitsuru Saito
- Department of Orthopedic Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Norimasa Iwasaki
- Department of Orthopedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Akio Minami
- Department of Orthopedic Surgery, Hokkaido Spinal Cord Injury Center, Bibai, Japan
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10
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Jaipanya P, Lertudomphonwanit T, Chanplakorn P, Pichyangkul P, Kraiwattanapong C, Keorochana G, Leelapattana P. Predictive factors for respiratory failure and in-hospital mortality after surgery for spinal metastasis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:1729-1740. [PMID: 36943483 DOI: 10.1007/s00586-023-07638-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 11/15/2022] [Accepted: 03/05/2023] [Indexed: 03/23/2023]
Abstract
PURPOSE Spinal metastasis surgeries carry substantial risk of complications. PRF is among complications that significantly increase mortality rate and length of hospital stay. The risk factor of PRF after spinal metastasis surgery has not been investigated. This study aims to identify the predictors of postoperative respiratory failure (PRF) and in-hospital death after spinal metastasis surgery. METHODS We retrospectively reviewed consecutive patients with spinal metastasis surgically treated between 2008 and 2018. PRF was defined as mechanical ventilator dependence > 48 h postoperatively (MVD) or unplanned postoperative intubation (UPI). Collected data include demographics, laboratory data, radiographic and operative data, and postoperative complications. Stepwise logistic regression analysis was used to determine predictors independently associated with PRFs and in-hospital death. RESULTS This study included 236 patients (average age 57 ± 14 years, 126 males). MVD and UPI occurred in 13 (5.5%) patients and 13 (5.5%) patients, respectively. During admission, 14 (5.9%) patients had died postoperatively. Multivariate logistic regression analysis revealed significant predictors of MVD included intraoperative blood loss > 2000 mL (odds ratio [OR] 12.28, 95% confidence interval [CI] 2.88-52.36), surgery involving cervical spine (OR 9.58, 95% CI 1.94-47.25), and ASA classification ≥ 4 (OR 6.59, 95% CI 1.85-23.42). The predictive factors of UPI included postoperative sepsis (OR 20.48, 95% CI 3.47-120.86), central nervous system (CNS) metastasis (OR 10.21, 95% CI 1.42-73.18), lung metastasis (OR 7.18, 95% CI 1.09-47.4), and postoperative pulmonary complications (OR 6.85, 95% CI 1.44-32.52). The predictive factors of in-hospital death included postoperative sepsis (OR 13.15, 95% CI 2.92-59.26), CNS metastasis (OR 10.55, 95% CI 1.54-72.05), and postoperative pulmonary complications (OR 9.87, 95% CI 2.35-41.45). CONCLUSION PRFs and in-hospital death are not uncommon after spinal metastasis surgery. Predictive factors for PRFs included preoperative comorbidities, intraoperative massive blood loss, and postoperative complications. Identification of risk factors may help guide therapeutic decision-making and patient counseling.
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Affiliation(s)
- Pilan Jaipanya
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 111 Suwannabhumi Canal Road, Bang Pla, Bang Phli District, Samut Prakan, 10540, Thailand
| | - Thamrong Lertudomphonwanit
- Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270, Rama VI Road, Thung Phaya Thai, Ratchathewi District, Bangkok, 10400, Thailand.
| | - Pongsthorn Chanplakorn
- Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270, Rama VI Road, Thung Phaya Thai, Ratchathewi District, Bangkok, 10400, Thailand
| | - Picharn Pichyangkul
- Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270, Rama VI Road, Thung Phaya Thai, Ratchathewi District, Bangkok, 10400, Thailand
| | - Chaiwat Kraiwattanapong
- Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270, Rama VI Road, Thung Phaya Thai, Ratchathewi District, Bangkok, 10400, Thailand
| | - Gun Keorochana
- Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270, Rama VI Road, Thung Phaya Thai, Ratchathewi District, Bangkok, 10400, Thailand
| | - Pittavat Leelapattana
- Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270, Rama VI Road, Thung Phaya Thai, Ratchathewi District, Bangkok, 10400, Thailand
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11
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Sharon M, Bardes JM, Riley H, Wagner A, Davis JK, Schaefer G, Wilson A, Khan U. A Comprehensive Spinal Cord Injury Treatment Protocol Improves Outcomes and Decreases Complications. Am Surg 2023; 89:1893-1898. [PMID: 35344395 PMCID: PMC9535684 DOI: 10.1177/00031348221074224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Spinal cord injury (SCI) is a devastating event with a complicated recovery. Through the use of an interdisciplinary team a comprehensive care plan was developed, utilizing all available best practices, to prevent secondary complications. Previous work has shown the benefit of single system protocols or interventions. This study aimed to assess changes in outcomes after implementation of a comprehensive protocol. MATERIAL AND METHODS This was a retrospective cohort study performed at an ACS Level I trauma center. It was based on data abstract from the institutions trauma registry over a 10 year period. Patients with quadriplegia after a traumatic injury were included. Data on hospital outcomes and complications was collected and compared before and after the use of the Spinal cord injury protocol. RESULTS 58 patients were evaluated. Overall, there was a reduction in complications after the implementation, with significant reductions in pneumonia (47% vs 16%; P = .02) and decubitus ulcers (47% to 11%; P = .005). ICU length of stay decreased by 7 days and hospital length of stay decreased 13 days. There was no difference in mortality. Hospital costs also decreased a mean of $42,000. CONCLUSIONS A comprehensive SCI protocol can reduce secondary complications in quadriplegic patients. This study found significant decreases in pneumonia and decubitus ulcer rates after implementation of the protocol. Lengths of stay and cost were also significantly reduced. Future research using comprehensive SCI protocols is needed to further assess its effects on outcomes for this specific patient population. Similar centers should consider adoption of comprehensive SCI protocols.
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Affiliation(s)
- Melinda Sharon
- Marshall University School of Medicine, Morgantown, WV, USA
| | | | - Holly Riley
- Department of Surgery, Division of Trauma, Surgical Critical Care and Acute Care Surgery, West Virginia University, Morgantown, WV, USA
| | - Afton Wagner
- Department of Surgery, Division of Trauma, Surgical Critical Care and Acute Care Surgery, West Virginia University, Morgantown, WV, USA
| | - Jennifer Knight Davis
- Department of Surgery, Division of Trauma, Surgical Critical Care and Acute Care Surgery, West Virginia University, Morgantown, WV, USA
| | - Gregory Schaefer
- Department of Surgery, Division of Trauma, Surgical Critical Care and Acute Care Surgery, West Virginia University, Morgantown, WV, USA
| | - Alison Wilson
- Department of Surgery, Division of Trauma, Surgical Critical Care and Acute Care Surgery, West Virginia University, Morgantown, WV, USA
| | - Uzer Khan
- Department of Surgery, Division of Trauma, Surgical Critical Care and Acute Care Surgery, West Virginia University, Morgantown, WV, USA
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12
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Gouveia D, Fonseca S, Carvalho C, Cardoso A, Almeida A, Gamboa Ó, Canejo-Teixeira R, Ferreira A, Martins Â. Clinical Occurrences in the Neurorehabilitation of Dogs with Severe Spinal Cord Injury. Animals (Basel) 2023; 13:ani13071164. [PMID: 37048421 PMCID: PMC10093106 DOI: 10.3390/ani13071164] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/19/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023] Open
Abstract
This prospective observational clinical study in a population of tetraplegic and paraplegic dogs (n = 488) with or without deep pain sensation, similar to humans ASIA A and B, investigated the prevalence of clinical occurrences in a rehabilitation center with a hospitalization regime between 15 days and 9 months. A checklist of occurrences was used for easy identification and monitoring, resulting in a total of 79.5% occurrences. There were 58% of dogs with neurogenic bladder, 35.5% with diarrhea, 21.3% with urinary incontinence, and 20.5% with fecal incontinence. A low incidence of respiratory problems (e.g., pneumonia) and urinary tract infections may suggest the efficacy of some applied measures in this study, such as thoracic and abdominal POCUS evaluation, positioning strategies, physical exercises, respiratory kinesiotherapy, and early implementation of a functional neurorehabilitation protocol. These can be essential measures to prevent clinical occurrences, mainly in breeds such as the French Bulldog and the Dachshund.
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Affiliation(s)
- Débora Gouveia
- Arrábida Veterinary Hospital, Arrábida Animal Rehabilitation Center, 2925-538 Setubal, Portugal
- Superior School of Health, Protection and Animal Welfare, Polytechnic Institute of Lusophony, 1950-396 Lisboa, Portugal
- Faculty of Veterinary Medicine, Lusófona University, 1749-024 Lisboa, Portugal
| | - Sara Fonseca
- Arrábida Veterinary Hospital, Arrábida Animal Rehabilitation Center, 2925-538 Setubal, Portugal
- Faculty of Veterinary Medicine, Lusófona University, 1749-024 Lisboa, Portugal
| | - Carla Carvalho
- Arrábida Veterinary Hospital, Arrábida Animal Rehabilitation Center, 2925-538 Setubal, Portugal
| | - Ana Cardoso
- Arrábida Veterinary Hospital, Arrábida Animal Rehabilitation Center, 2925-538 Setubal, Portugal
| | - António Almeida
- Faculty of Veterinary Medicine, University of Lisbon, 1300-477 Lisboa, Portugal
| | - Óscar Gamboa
- Faculty of Veterinary Medicine, University of Lisbon, 1300-477 Lisboa, Portugal
| | - Rute Canejo-Teixeira
- Superior School of Health, Protection and Animal Welfare, Polytechnic Institute of Lusophony, 1950-396 Lisboa, Portugal
- Faculty of Veterinary Medicine, Lusófona University, 1749-024 Lisboa, Portugal
| | - António Ferreira
- Faculty of Veterinary Medicine, University of Lisbon, 1300-477 Lisboa, Portugal
| | - Ângela Martins
- Arrábida Veterinary Hospital, Arrábida Animal Rehabilitation Center, 2925-538 Setubal, Portugal
- Superior School of Health, Protection and Animal Welfare, Polytechnic Institute of Lusophony, 1950-396 Lisboa, Portugal
- Faculty of Veterinary Medicine, Lusófona University, 1749-024 Lisboa, Portugal
- Correspondence:
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13
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Wulf MJ, Tom VJ. Consequences of spinal cord injury on the sympathetic nervous system. Front Cell Neurosci 2023; 17:999253. [PMID: 36925966 PMCID: PMC10011113 DOI: 10.3389/fncel.2023.999253] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 02/09/2023] [Indexed: 03/06/2023] Open
Abstract
Spinal cord injury (SCI) damages multiple structures at the lesion site, including ascending, descending, and propriospinal axons; interrupting the conduction of information up and down the spinal cord. Additionally, axons associated with the autonomic nervous system that control involuntary physiological functions course through the spinal cord. Moreover, sympathetic, and parasympathetic preganglionic neurons reside in the spinal cord. Thus, depending on the level of an SCI, autonomic function can be greatly impacted by the trauma resulting in dysfunction of various organs. For example, SCI can lead to dysregulation of a variety of organs, such as the pineal gland, the heart and vasculature, lungs, spleen, kidneys, and bladder. Indeed, it is becoming more apparent that many disorders that negatively affect quality-of-life for SCI individuals have a basis in dysregulation of the sympathetic nervous system. Here, we will review how SCI impacts the sympathetic nervous system and how that negatively impacts target organs that receive sympathetic innervation. A deeper understanding of this may offer potential therapeutic insight into how to improve health and quality-of-life for those living with SCI.
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Affiliation(s)
| | - Veronica J. Tom
- Marion Murray Spinal Cord Research Center, Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA, United States
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14
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Peng H, Liu Y, Xiao F, Zhang L, Li W, Wang B, Weng Z, Liu Y, Chen G. Research progress of hydrogels as delivery systems and scaffolds in the treatment of secondary spinal cord injury. Front Bioeng Biotechnol 2023; 11:1111882. [PMID: 36741755 PMCID: PMC9889880 DOI: 10.3389/fbioe.2023.1111882] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/09/2023] [Indexed: 01/19/2023] Open
Abstract
Secondary spinal cord injury (SSCI) is the second stage of spinal cord injury (SCI) and involves vasculature derangement, immune response, inflammatory response, and glial scar formation. Bioactive additives, such as drugs and cells, have been widely used to inhibit the progression of secondary spinal cord injury. However, the delivery and long-term retention of these additives remain a problem to be solved. In recent years, hydrogels have attracted much attention as a popular delivery system for loading cells and drugs for secondary spinal cord injury therapy. After implantation into the site of spinal cord injury, hydrogels can deliver bioactive additives in situ and induce the unidirectional growth of nerve cells as scaffolds. In addition, physical and chemical methods can endow hydrogels with new functions. In this review, we summarize the current state of various hydrogel delivery systems for secondary spinal cord injury treatment. Moreover, functional modifications of these hydrogels for better therapeutic effects are also discussed to provide a comprehensive insight into the application of hydrogels in the treatment of secondary spinal cord injury.
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Affiliation(s)
- Haichuan Peng
- Guangdong Provincial Key Laboratory of Tumor Interventional Diagnosis and Treatment, Zhuhai People’s Hospital (Zhuhai Hospital Affiliated with Jinan University), Zhuhai, China
| | - Yongkang Liu
- The Department of Cerebrovascular Disease, Zhuhai People’s Hospital (Zhuhai Hospital Affiliated with Jinan University), Zhuhai, China
| | - Fengfeng Xiao
- Guangdong Provincial Key Laboratory of Tumor Interventional Diagnosis and Treatment, Zhuhai People’s Hospital (Zhuhai Hospital Affiliated with Jinan University), Zhuhai, China
| | - Limei Zhang
- Guangdong Provincial Key Laboratory of Tumor Interventional Diagnosis and Treatment, Zhuhai People’s Hospital (Zhuhai Hospital Affiliated with Jinan University), Zhuhai, China
| | - Wenting Li
- Guangdong Provincial Key Laboratory of Tumor Interventional Diagnosis and Treatment, Zhuhai People’s Hospital (Zhuhai Hospital Affiliated with Jinan University), Zhuhai, China
| | - Binghan Wang
- Zhuhai Precision Medical Center, Zhuhai People’s Hospital (Zhuhai Hospital Affiliated with Jinan University), Zhuhai, China
| | - Zhijian Weng
- The Department of Neurosurgery, Zhuhai People’s Hospital (Zhuhai Hospital Affiliated with Jinan University), Zhuhai, China
| | - Yu Liu
- The Department of Cerebrovascular Disease, Zhuhai People’s Hospital (Zhuhai Hospital Affiliated with Jinan University), Zhuhai, China,*Correspondence: Yu Liu, ; Gang Chen,
| | - Gang Chen
- The Department of Neurosurgery, Zhuhai People’s Hospital (Zhuhai Hospital Affiliated with Jinan University), Zhuhai, China,*Correspondence: Yu Liu, ; Gang Chen,
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15
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Kobayashi M, Yokogawa N, Kato S, Sasagawa T, Tsuchiya H, Nakashima H, Segi N, Ito S, Funayama T, Eto F, Yamaji A, Yamane J, Nori S, Furuya T, Yunde A, Nakajima H, Yamada T, Hasegawa T, Terashima Y, Hirota R, Suzuki H, Imajo Y, Ikegami S, Uehara M, Tonomura H, Sakata M, Hashimoto K, Onoda Y, Kawaguchi K, Haruta Y, Suzuki N, Kato K, Uei H, Sawada H, Nakanishi K, Misaki K, Terai H, Tamai K, Kuroda A, Inoue G, Kakutani K, Kakiuchi Y, Kiyasu K, Tominaga H, Tokumoto H, Iizuka Y, Takasawa E, Akeda K, Takegami N, Funao H, Oshima Y, Kaito T, Sakai D, Yoshii T, Ohba T, Otsuki B, Seki S, Miyazaki M, Ishihara M, Okada S, Imagama S, Watanabe K. Risk Factors for Early Mortality in Older Patients with Traumatic Cervical Spine Injuries-A Multicenter Retrospective Study of 1512 Cases. J Clin Med 2023; 12:jcm12020708. [PMID: 36675636 PMCID: PMC9865717 DOI: 10.3390/jcm12020708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/19/2022] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
For older patients with decreased reserve function, traumatic cervical spine injuries frequently lead to early mortality. However, the prognostic factors for early mortality remain unclear. This study included patients aged ≥65 years and hospitalized for treatment of traumatic cervical spine injuries in 78 hospitals between 2010 and 2020. Early mortality was defined as death within 90 days after injury. We evaluated the relationship between early mortality and the following factors: age, sex, body mass index, history of drinking and smoking, injury mechanisms, presence of a cervical spine fracture and dislocation, cervical ossification of the posterior longitudinal ligament, diffuse idiopathic skeletal hyperostosis, American Spinal Injury Association Impairment Scale, concomitant injury, pre-existing comorbidities, steroid administration, and treatment plan. Overall, 1512 patients (mean age, 75.8 ± 6.9 years) were included in the study. The early mortality rate was 4.0%. Multivariate analysis identified older age (OR = 1.1, p < 0.001), male sex (OR = 3.7, p = 0.009), cervical spine fracture (OR = 4.2, p < 0.001), complete motor paralysis (OR = 8.4, p < 0.001), and chronic kidney disease (OR = 5.3, p < 0.001) as risk factors for early mortality. Older age, male sex, cervical spine fracture, complete motor paralysis, and chronic kidney disease are prognostic factors for early mortality in older patients with traumatic cervical spine injuries.
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Affiliation(s)
- Motoya Kobayashi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa 920-8641, Japan
| | - Noriaki Yokogawa
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa 920-8641, Japan
| | - Satoshi Kato
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa 920-8641, Japan
- Correspondence: ; Tel.: +81-76-265-2374
| | - Takeshi Sasagawa
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa 920-8641, Japan
- Department of Orthopaedic Surgery, Toyama Prefectural Central Hospital, Toyama 930-8550, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa 920-8641, Japan
| | - Hiroaki Nakashima
- Department of Orthopedic Surgery, Graduate School of Medicine, Nagoya University, Nagoya 466-8550, Japan
| | - Naoki Segi
- Department of Orthopedic Surgery, Graduate School of Medicine, Nagoya University, Nagoya 466-8550, Japan
| | - Sadayuki Ito
- Department of Orthopedic Surgery, Graduate School of Medicine, Nagoya University, Nagoya 466-8550, Japan
| | - Toru Funayama
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba 305-8575, Japan
| | - Fumihiko Eto
- Department of Orthopaedic Surgery, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba 305-8575, Japan
| | - Akihiro Yamaji
- Department of Orthopaedic Surgery, Ibaraki Seinan Medical Center Hospital, Sakai 306-0433, Japan
| | - Junichi Yamane
- Department of Orthopaedic Surgery, National Hospital Organization Murayama Medical Center, Tokyo 208-0011, Japan
| | - Satoshi Nori
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Takeo Furuya
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan
| | - Atsushi Yunde
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan
| | - Hideaki Nakajima
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences, University of Fukui, Fukui 910-1193, Japan
| | - Tomohiro Yamada
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Shizuoka 431-3192, Japan
- Department of Orthopaedic Surgery, Nagoya Kyoritsu Hospital, Nagoya-shi 454-0933, Japan
| | - Tomohiko Hasegawa
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Shizuoka 431-3192, Japan
| | - Yoshinori Terashima
- Department of Orthopaedic Surgery, Sapporo Medical University, Sapporo 060-8543, Japan
- Department of Orthopaedic Surgery, Matsuda Orthopedic Memorial Hospital, Sapporo 001-0018, Japan
| | - Ryosuke Hirota
- Department of Orthopaedic Surgery, Sapporo Medical University, Sapporo 060-8543, Japan
| | - Hidenori Suzuki
- Department of Orthopaedic Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi 755-8505, Japan
| | - Yasuaki Imajo
- Department of Orthopaedic Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi 755-8505, Japan
| | - Shota Ikegami
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Nagano 390-8621, Japan
| | - Masashi Uehara
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Nagano 390-8621, Japan
| | - Hitoshi Tonomura
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan
| | - Munehiro Sakata
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan
- Department of Orthopaedics, Saiseikai Shiga Hospital, Ritto 520-3046, Japan
| | - Ko Hashimoto
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
| | - Yoshito Onoda
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
| | - Kenichi Kawaguchi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi Higashi-ku, Fukuoka 812-8582, Japan
| | - Yohei Haruta
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi Higashi-ku, Fukuoka 812-8582, Japan
| | - Nobuyuki Suzuki
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya 467-8601, Japan
| | - Kenji Kato
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya 467-8601, Japan
| | - Hiroshi Uei
- Department of Orthopaedic Surgery, Nihon University Hospital, Tokyo 101-8393, Japan
- Department of Orthopaedic Surgery, Nihon University School of Medicine, Tokyo 173-8610, Japan
| | - Hirokatsu Sawada
- Department of Orthopaedic Surgery, Nihon University School of Medicine, Tokyo 173-8610, Japan
| | - Kazuo Nakanishi
- Department of Orthopedics, Traumatology and Spine Surgery, Kawasaki Medical School, Okayama 701-0192, Japan
| | - Kosuke Misaki
- Department of Orthopedics, Traumatology and Spine Surgery, Kawasaki Medical School, Okayama 701-0192, Japan
| | - Hidetomi Terai
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Koji Tamai
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Akiyoshi Kuroda
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, Sagamihara 252-0374, Japan
| | - Gen Inoue
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, Sagamihara 252-0374, Japan
| | - Kenichiro Kakutani
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
| | - Yuji Kakiuchi
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
| | - Katsuhito Kiyasu
- Department of Orthopaedic Surgery, Kochi Medical School, Kochi University, Nankoku 783-8505, Japan
| | - Hiroyuki Tominaga
- Department of Orthopaedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima 890-8520, Japan
| | - Hiroto Tokumoto
- Department of Orthopaedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima 890-8520, Japan
| | - Yoichi Iizuka
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Maebashi 371-8511, Japan
| | - Eiji Takasawa
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Maebashi 371-8511, Japan
| | - Koji Akeda
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Mie Tsu City 514-8507, Japan
| | - Norihiko Takegami
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Mie Tsu City 514-8507, Japan
| | - Haruki Funao
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Chiba 286-0124, Japan
- Department of Orthopaedic Surgery, International University of Health and Welfare Narita Hospital, Chiba 286-0124, Japan
- Department of Orthopaedic Surgery and Spine and Spinal Cord Center, International University of Health and Welfare Mita Hospital, Tokyo 108-8329, Japan
| | - Yasushi Oshima
- Department of Orthopaedic Surgery, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Takashi Kaito
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Daisuke Sakai
- Department of Orthopedics Surgery, Surgical Science, Tokai University School of Medicine, Isehara 259-1193, Japan
| | - Toshitaka Yoshii
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, Tokyo 113-8519, Japan
| | - Tetsuro Ohba
- Department of Orthopaedic Surgery, University of Yamanashi, Yamanashi 409-3898, Japan
| | - Bungo Otsuki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Shoji Seki
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama 930-0194, Japan
| | - Masashi Miyazaki
- Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, Yufu-shi 879-5593, Japan
| | - Masayuki Ishihara
- Department of Orthopaedic Surgery, Kansai Medical University Hospital, Osaka 573-1191, Japan
| | - Seiji Okada
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Graduate School of Medicine, Nagoya University, Nagoya 466-8550, Japan
| | - Kota Watanabe
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
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McNaughton KMD, Witherow JL, Dupuche CB, Peebles KC, Elphick TG, Hudson AL, McCaughey EJ, Boswell-Ruys CL, Butler JE. Inspiratory muscle reflex control after incomplete cervical spinal cord injury. J Appl Physiol (1985) 2022; 133:1318-1326. [PMID: 36356259 DOI: 10.1152/japplphysiol.00113.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
In healthy individuals, loading inspiratory muscles by brief inspiratory occlusion produces a short-latency inhibitory reflex (IR) in the electromyographic (EMG) activity of scalene and diaphragm muscles. This IR may play a protective role to prevent aspiration and airway collapse during sleep. In people with motor and sensory complete cervical spinal cord injury (cSCI), who were able to breathe independently, this IR was predominantly absent. Here, we investigated the reflex response to brief airway occlusion in 16 participants with sensory incomplete cSCI [American spinal injury association impairment scale (AIS) score B or C]. Surface EMG was recorded from scalene muscles and the lateral chest wall (overlying diaphragm). The airway occlusion evoked a small change in mouth pressure resembling a physiological occlusion. The short-latency IR was present in 10 (63%) sensory incomplete cSCI participants; significantly higher than the IR incidence observed in complete cSCI participants in our previous study (14%; P = 0.003). When present, mean IR latency across all muscles was 58 ms (range 29-79 ms), and mean rectified EMG amplitude decreased to 37% preocclusion levels. Participants without an IR had untreated severe obstructive sleep apnea (OSA), in contrast to those with an IR, who had either had no, mild, or treated OSA (P = 0.002). Insufficient power did not allow statistical comparison between IR presence or absence and participant clinical characteristics. In conclusion, spared sensory connections or intersegmental connections may be necessary to generate the IR. Future studies to establish whether IR presence is related to respiratory morbidity in the tetraplegic population are required.NEW & NOTEWORTHY Individuals with incomplete cSCI were tested for the presence of a short latency reflex inhibition of inspiratory muscles, by brief airway occlusion. The reflex was 4.5 times more prevalent in this group compared with those with complete cSCI and is similar to the incidence in able-bodied people. Participants without this reflex all had untreated severe OSA, in contrast to those with an IR, who either had no, mild, or treated OSA. This work reveals novel differences in the reflex control of inspiratory muscles across the cSCI population.
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Affiliation(s)
- Keith M D McNaughton
- Neuroscience Research Australia, Randwick, New South Wales, Australia.,Department of Health Sciences, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Jessica L Witherow
- Department of Health Sciences, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Crystal B Dupuche
- Department of Health Sciences, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Karen C Peebles
- Department of Health Sciences, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Tom G Elphick
- School of Medical Sciences, University of New South Wales, Kensington, New South Wales, Australia
| | - Anna L Hudson
- Neuroscience Research Australia, Randwick, New South Wales, Australia.,School of Medical Sciences, University of New South Wales, Kensington, New South Wales, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Euan J McCaughey
- Neuroscience Research Australia, Randwick, New South Wales, Australia.,School of Medical Sciences, University of New South Wales, Kensington, New South Wales, Australia.,Queen Elizabeth National Spinal Injuries Unit, Glasgow, United Kingdom
| | - Claire L Boswell-Ruys
- Neuroscience Research Australia, Randwick, New South Wales, Australia.,Department of Physiotherapy, Prince of Wales Hospital, Randwick, New South Wales, Australia.,School of Medical Sciences, University of New South Wales, Kensington, New South Wales, Australia
| | - Jane E Butler
- School of Medical Sciences, University of New South Wales, Kensington, New South Wales, Australia
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Sengupta D, Bindra A, Kapoor I, Mathur P, Gupta D, Khan MA. Comparison of Different Tidal Volumes for Ventilation in Patients with an Acute Traumatic Cervical Spine Injury. Neurol India 2022; 70:S282-S287. [PMID: 36412382 DOI: 10.4103/0028-3886.360926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background There is scant literature comparing high tidal volume ventilation (HTV) over low tidal volume (LTV) ventilation in acute traumatic cervical spinal cord injury (CSCI). Objective The aim of this prospective randomized controlled parallel-group, single-blinded study was to compare the effect of two different tidal volumes (12-15 mL/kg and 6-8 mL/kg) in CSCI on days to achieve ventilator-free breathing (VFB), PaO2/FIO2 ratio, the incidence of complications, requirement of vasopressor drugs, total duration of hospital stay, and mortality. Materials and Methods We enrolled patients with acute high traumatic CSCI admitted to the neurotrauma intensive care unit within 24 h of injury, requiring mechanical ventilation. Participants were randomized to receive either HTV, 12-15 mL/kg (group H) or LTV, 6-8 mL/kg (group L) tidal volume ventilation. Results and Conclusions A total of 56 patients, 28 in each group were analyzed. Patient demographics and injury severity were comparable between the groups. VFB was achieved in 23 and 19 patients in groups H and L, respectively. The median number of days required to achieve VFB was 3 (2, 56) and 8 (2, 50) days, P = 0.33; PaO2: FIO2 ratio was 364.0 ± 64 and 321.0 ± 67.0, P = 0.01; the incidence of atelectasis was 25% and 46%, P = 0.16, respectively, in group H and group L. The hemodynamic parameters and the vasopressor requirement were comparable in both groups. There was no barotrauma. The duration of hospital stay (P = 0.2) and mortality (P = 0.2) was comparable in both groups. There was no significant difference in days to achieve ventilator-free breathing with HTV (12-15 mL/kg) ventilation compared to LTV (6-8 mL/kg) ventilation in acute CSCI. The PaO2:FiO2 ratio was higher with the use of 12-15 mL/kg. No difference in mortality and duration of hospital stay was seen in either group.
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Affiliation(s)
- Deep Sengupta
- Neuroanaesthesiology and Critical Care, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Ashish Bindra
- Neuroanaesthesiology and Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Indu Kapoor
- Neuroanaesthesiology and Critical Care, Cardio-Neuro Centre, All India Institute of Medical Sciences, New Delhi, New Delhi, India
| | - Purva Mathur
- Microbiology, Lab Medicine, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Gupta
- Department of Neurosurgery, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Maroof A Khan
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, New Delhi, India
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Erfani Z, Jelodari Mamaghani H, Rawling JA, Eajazi A, Deever D, Mirmoeeni S, Azari Jafari A, Seifi A. Pneumonia in Nervous System Injuries: An Analytic Review of Literature and Recommendations. Cureus 2022; 14:e25616. [PMID: 35784955 PMCID: PMC9249029 DOI: 10.7759/cureus.25616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2022] [Indexed: 11/09/2022] Open
Abstract
Pneumonia is one of the most common complications in intensive care units and is the most common nosocomial infection in this setting. Patients with neurocritical conditions who are admitted to ICUs are no exception, and in fact, are more prone to infections such as pneumonia because of factors such as swallow dysfunction, need for mechanical ventilation, longer length of stay in hospitals, etc. Common central nervous system pathologies such as ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, intracerebral hemorrhage, neuromuscular disorders, status epilepticus, and demyelinating diseases can cause long in-hospital admissions and increase the risk of pneumonia each with a mechanism of its own. Brain injury-induced immunosuppression syndrome is usually considered the common mechanism through which patients with critical central nervous system conditions become susceptible to different kinds of infection including pneumonia. Evaluating the patients and assessment of the risk factors can lead our attention toward better infection control in this population and therefore decrease the risk of infections in central nervous system injuries.
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Gaignard SM, Jiang AQ, Coleman CG, Spicer JO, Phadke VK. A 42-Year-Old Man with Back Pain and Lower Extremity Weakness. NEJM EVIDENCE 2022; 1:EVIDmr2200088. [PMID: 38319248 DOI: 10.1056/evidmr2200088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Back Pain and Lower-Extremity WeaknessA 42-year-old man with HIV presented for evaluation of acute-onset back pain and lower-extremity weakness. How do you approach the evaluation, and what is the diagnosis?
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Affiliation(s)
- Scott M Gaignard
- from the Emory University School of Medicine J. Willis Hurst Internal Medicine Residency Program
| | - Alice Q Jiang
- from the Emory University School of Medicine J. Willis Hurst Internal Medicine Residency Program
| | - Caroline G Coleman
- from the Emory University School of Medicine J. Willis Hurst Internal Medicine Residency Program
| | - Jennifer O Spicer
- from the Emory University School of Medicine J. Willis Hurst Internal Medicine Residency Program
| | - Varun K Phadke
- from the Emory University School of Medicine J. Willis Hurst Internal Medicine Residency Program
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20
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Pulmonary rehabilitation in high cervical spinal cord injury: a series of 133 consecutive cases. Spinal Cord 2022; 60:1014-1019. [DOI: 10.1038/s41393-022-00816-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 05/16/2022] [Accepted: 05/17/2022] [Indexed: 11/08/2022]
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21
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Mesenchymal Stem Cell Derived Exosomes Suppress Neuronal Cell Ferroptosis Via lncGm36569/miR-5627-5p/FSP1 Axis in Acute Spinal Cord Injury. Stem Cell Rev Rep 2022; 18:1127-1142. [DOI: 10.1007/s12015-022-10327-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/01/2022] [Indexed: 02/08/2023]
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22
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The incidence, clinical characteristics, and outcome of polytrauma patients with the combination of pulmonary contusion, flail chest and upper thoracic spinal injury. Injury 2022; 53:1073-1080. [PMID: 34625240 DOI: 10.1016/j.injury.2021.09.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 05/12/2021] [Accepted: 09/26/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Chest trauma was the third most common cause of death in polytrauma patients, accounting for 25% of all deaths from traumatic injury. Chest trauma involves in injury to the bony thorax, intrathoracic organs and thoracic medulla. This study aimed to investigate the incidence, clinical characteristics, and outcome of polytrauma patients with pulmonary contusion, flail chest and upper thoracic spinal injury. METHODS Patients who met inclusion criteria were divided into groups: Pulmonary contusion group (PC); Pulmonary contusion and flail chest group (PC + FC); Pulmonary contusion and upper thoracic spinal cord injury group (PC + UTSCI); Thoracic trauma triad group (TTT): included patients with flail chest, pulmonary contusion and the upper thoracic spinal cord injury coexisted. Outcomes were determined, including 30-day mortality and 6-month mortality. RESULTS A total 84 patients (2.0%) with TTT out of 4176 polytrauma patients presented to Tongji trauma center. There was no difference in mean ISS among PC + FC group, PC + UTSCI group and TTT group. Patients with TTT had a longer ICU stay (21.4 days vs. 7.5 and 6.2; p<0.01), relatively higher 30-day mortality (40.5% vs. 6.0% and 4.3%; p<0.01), and especially higher 6-month mortality (71.4% vs. 6.5%, 13.0%; p<0.01), compared to patients with PC + FC or with PC + UTSCI. The leading causes of death for patients with TTT were ARDS (44.1%) and pulmonary infection (26.5%) during first 30 days after admission. For those patients who died later than 30 days during the 6 months, the predominant underlying cause of death was MOF (53.8%). CONCLUSIONS Lethal triad of thoracic trauma (LTTT) were described in this study, which consisting of pulmonary contusion,flail chest and the upper thoracic spine cord injury. Like the classic "lethal triad", there was a synergy between the factors when they coexist, resulting in especially high mortality rates. Polytrauma patients with LTTT were presented relatively high 30-day mortality and 6 months mortality. We should pay much more attention to the patients with LTTT for further minimizing complications and mortality.
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In-hospital mortality in people with complete acute traumatic spinal cord injury at a tertiary care center in India-a retrospective analysis. Spinal Cord 2022; 60:210-215. [PMID: 34172928 PMCID: PMC8231086 DOI: 10.1038/s41393-021-00657-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 06/12/2021] [Accepted: 06/14/2021] [Indexed: 02/06/2023]
Abstract
STUDY DESIGN This is a retrospective study. OBJECTIVES To analyze the causes and risk factors of mortality in people admitted with complete acute traumatic spinal cord injury (ATSCI). SETTING The study was performed at the Indian Spinal Injuries Centre, New Delhi. METHODS Data between 2000 and 2016 were retrospectively collected from case records of people with ATSCI. Risk factors for mortality were examined using multivariable logistic regression. RESULTS Mortality rate in ATSCI admissions (n = 758) during the study period was 10%. Median (IQR) age of study participants was 34 (21) years with a range of 14-85 years. Respiratory complications, septicemia, and cardiovascular causes were responsible for 42%, 28, and 18% of deaths. Mortality rate in people with paraplegia and tetraplegia was 3% and 22%, respectively. The proportion surviving at 6 weeks was significantly different across people with paraplegia and people with high and low tetraplegia (p < 0.001). Greater age (OR (multivariable models) = 1.03, 95% CI = 1.01-1.06), associated injuries (OR = 2.42, 95% CI = 1.11-5.27), high tetraplegia (OR = 5.09, 95% CI = 2.21-11.72), low tetraplegia (OR = 4.84, 95% CI = 1.29-18.09), need for ventilator support (OR = 31.32, 95% CI = 14.92-65.35), septicemia (OR = 4.60, 95% CI = 1.05-20.07), respiratory complications (OR = 3.46, 95% CI = 1.63-7.33), and cardiovascular causes (OR = 39.03, 95% CI = 8.29-183.89) were significant risk factors associated with mortality. CONCLUSION Respiratory complications, septicemia, and cardiovascular causes were the commonest causes of in-hospital mortality in people with complete ATSCI. Greater age, presence of associated injuries, tetraplegia, and ventilator support were risk factors significantly associated with mortality. To reduce morbidity and mortality in the acute phase, there is a need to focus on respiratory management and prevention of infections, especially in tetraplegics.
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Taran S, McCredie VA, Goligher EC. Noninvasive and invasive mechanical ventilation for neurologic disorders. HANDBOOK OF CLINICAL NEUROLOGY 2022; 189:361-386. [PMID: 36031314 DOI: 10.1016/b978-0-323-91532-8.00015-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Patients with acute neurologic injuries frequently require mechanical ventilation due to diminished airway protective reflexes, cardiopulmonary failure secondary to neurologic insults, or to facilitate gas exchange to precise targets. Mechanical ventilation enables tight control of oxygenation and carbon dioxide levels, enabling clinicians to modulate cerebral hemodynamics and intracranial pressure with the goal of minimizing secondary brain injury. In patients with acute spinal cord injuries, neuromuscular conditions, or diseases of the peripheral nerve, mechanical ventilation enables respiratory support under conditions of impending or established respiratory failure. Noninvasive ventilatory approaches may be carefully considered for certain disease conditions, including myasthenia gravis and amyotrophic lateral sclerosis, but may be inappropriate in patients with Guillain-Barré syndrome or when relevant contra-indications exist. With regard to discontinuing mechanical ventilation, considerable uncertainty persists about the best approach to wean patients, how to identify patients ready for extubation, and when to consider primary tracheostomy. Recent consensus guidelines highlight these and other knowledge gaps that are the focus of active research efforts. This chapter outlines important general principles to consider when initiating, titrating, and discontinuing mechanical ventilation in patients with acute neurologic injuries. Important disease-specific considerations are also reviewed where appropriate.
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Affiliation(s)
- Shaurya Taran
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Victoria A McCredie
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Department of Medicine, University Health Network, Toronto, ON, Canada.
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Foran SJ, Taran S, Singh JM, Kutsogiannis DJ, McCredie V. Timing of tracheostomy in acute traumatic spinal cord injury: A systematic review and meta-analysis. J Trauma Acute Care Surg 2022; 92:223-231. [PMID: 34508010 PMCID: PMC8677619 DOI: 10.1097/ta.0000000000003394] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/04/2021] [Accepted: 08/20/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with acute traumatic cervical or high thoracic level spinal cord injury (SCI) typically require mechanical ventilation (MV) during their acute admission. Placement of a tracheostomy is preferred when prolonged weaning from MV is anticipated. However, the optimal timing of tracheostomy placement in patients with acute traumatic SCI remains uncertain. We systematically reviewed the literature to determine the effects of early versus late tracheostomy or prolonged intubation in patients with acute traumatic SCI on important clinical outcomes. METHODS Six databases were searched from their inception to January 2020. Conference abstracts from relevant proceedings and the gray literature were searched to identify additional studies. Data were obtained by two independent reviewers to ensure accuracy and completeness. The quality of observational studies was evaluated using the Newcastle Ottawa Scale. RESULTS Seventeen studies (2,804 patients) met selection criteria, 14 of which were published after 2009. Meta-analysis showed that early tracheostomy was not associated with decreased short-term mortality (risk ratio [RR], 0.84; 95% confidence interval [CI], 0.39-1.79; p = 0.65; n = 2,072), but was associated with a reduction in MV duration (mean difference [MD], 13.1 days; 95% CI, -6.70 to -21.11; p = 0.0002; n = 855), intensive care unit length of stay (MD, -10.20 days; 95% CI, -4.66 to -15.74; p = 0.0003; n = 855), and hospital length of stay (MD, -7.39 days; 95% CI, -3.74 to -11.03; p < 0.0001; n = 423). Early tracheostomy was also associated with a decreased incidence of ventilator-associated pneumonia and tracheostomy-related complications (RR, 0.86; 95% CI, 0.75-0.98; p = 0.02; n = 2,043 and RR, 0.64; 95% CI, 0.48-0.84; p = 0.001; n = 812 respectively). The majority of studies ranked as good methodologic quality on the Newcastle Ottawa Scale. CONCLUSION Early tracheostomy in patients with acute traumatic SCI may reduce duration of mechanical entilation, length of intensive care unit stay, and length of hospital stay. Current studies highlight the lack of high-level evidence to guide the optimal timing of tracheostomy in acute traumatic SCI. Future research should seek to understand whether early tracheostomy improves patient comfort, decreases duration of sedation, and improves long-term outcomes. LEVEL OF EVIDENCE Systematic Review, level III.
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Satkunendrarajah K, Karadimas SK, Fehlings MG. Spinal cord injury and degenerative cervical myelopathy. HANDBOOK OF CLINICAL NEUROLOGY 2022; 189:241-257. [PMID: 36031307 DOI: 10.1016/b978-0-323-91532-8.00006-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Spinal cord injury (SCI) often results in impaired respiratory function. Paresis or paralysis of inspiratory and expiratory muscles can lead to respiratory dysfunction depending on the level and severity of the injury, which can affect the management and care of SCI patients. Respiratory dysfunction after SCI is more severe in high cervical injuries, with vital capacity (VC) being an essential indicator of overall respiratory health. Respiratory complications include hypoventilation, a reduction in surfactant production, mucus plugging, atelectasis, and pneumonia. Respiratory management includes mechanical ventilation and tracheostomy in high cervical SCI, while noninvasive ventilation is more common in patients with lower cervical and thoracic injuries. Mechanical ventilation can negatively impact the function of the diaphragm and weaning should start as soon as possible. Patients can sometimes be weaned from mechanical ventilation with assistance of electrical stimulation of the phrenic nerve or the diaphragm. Respiratory muscle training regimens may also improve patients' inspiratory function following SCI. Despite the critical advances in preventing, diagnosing, and treating respiratory complications, they continue to significantly affect persons living with SCI. Additional studies of interventions to reduce respiratory complications are likely to further decrease the morbidity and mortality associated with these injuries.
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Affiliation(s)
- Kajana Satkunendrarajah
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States; Department of Neuroscience, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI, United States; Department of Physiology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Spyridon K Karadimas
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Michael G Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada; Division of Genetics and Development, Krembil Brain Institute, University Health Network, Toronto, ON, Canada.
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McRae J, Hayton J, Smith C. Speech and language therapy service provision in spinal injury units compared to major trauma centres in England: Are services matched? INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS 2022; 57:6-20. [PMID: 34510665 DOI: 10.1111/1460-6984.12671] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/17/2021] [Accepted: 08/18/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND National UK guidance makes recommendations for speech and language therapy staffing levels in critical care and rehabilitation settings. Traumatic spinal cord injury patients often require admission primarily to critical care services within a major trauma centre prior to transfer to a specialist spinal injury unit but may not receive similar levels of care. Dysphagia and communication difficulties are recognised features of cervical spinal cord injury; however, little is known about access to speech and language therapy services to provide rehabilitation and improve outcomes. AIMS The aim of this study was to compare the workforce and clinical practices of speech and language therapy services in eight spinal injury units and four major trauma centres in England through an online survey. METHODS & PROCEDURES An online survey was created with 26 multiple-choice questions across seven sub-sections, with options for free-text comments. These were sent to a named speech and language therapy contact at each of the specified units. Responses were uploaded into Excel for analyses, which included descriptive statistics and analysis of themes. OUTCOMES & RESULTS Responses were received from 92% (11/12) speech and language therapy services invited, which included seven out of eight spinal injury units and all four major trauma centres. No units met national staffing recommendations. Staff in spinal injury units provided an average of 27 h per week input to the unit compared to 80 h in a major trauma centre. Despite caseload variations, speech and language range of therapy involvement and prioritisation process were equivalent. Access to instrumental assessment varied, with less use of Fibreoptic Endoscopic Evaluation of Swallowing in spinal injury units despite its clinical value to the spinal cord injury caseload. CONCLUSIONS & IMPLICATIONS Speech and language therapy services delivering post-acute and long-term rehabilitation to spinal cord injury patients are limited by their resources and capacity, which restricts the level of therapy delivered to patients. This may have an impact on clinical outcomes for communication and swallowing impairments. Further evidence is needed of the interventions delivered by speech and language therapists and outcomes will be beneficial alongside benchmarking similar services. WHAT THIS PAPER ADDS What is already known on this subject In England, people who sustain a spinal cord injury are admitted to a major trauma centre prior to transfer to a specialist spinal injury unit. Dysphagia and communication impairments are recognised as a complication of cervical spinal cord injury and benefit from speech and language therapy intervention. National recommendations exist for staffing levels, expertise and competencies for speech and language therapists working in critical care and rehabilitation units. What this study adds This study identified variations in the levels of speech and language therapy staffing, seniority, service delivery and access to instrumental assessments for dysphagia between major trauma centres and spinal injury units. None of the services complied with national staffing recommendations. Clinical implications of this study Speech and language therapy services in spinal injury units are often available part-time or have limited access to diagnostic tools which limits the range and intensity of rehabilitation input available. This has clinical implications for outcomes for swallowing and communication as well as long-term consequences for integrating back into community.
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Affiliation(s)
- Jackie McRae
- Centre for Allied Health, Kingston University and St George's University of London, London, UK
- Acute Speech and Language Therapy Team, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jennifer Hayton
- MSc Speech and Language Sciences, University College London, London, UK
| | - Christina Smith
- Psychology and Language Sciences, Faculty of Brain Sciences, University College London, London, UK
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Navarro JC, Kofke WA. Perioperative Management of Acute Central Nervous System Injury. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00024-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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Systematic Review of Incidence Studies of Pneumonia in Persons with Spinal Cord Injury. J Clin Med 2021; 11:jcm11010211. [PMID: 35011951 PMCID: PMC8745509 DOI: 10.3390/jcm11010211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/23/2021] [Accepted: 12/26/2021] [Indexed: 11/28/2022] Open
Abstract
Pneumonia continues to complicate the course of spinal cord injury (SCI). Currently, clinicians and policy-makers are faced with only limited numbers of pneumonia incidence in the literature. A systematic review of the literature was undertaken to provide an objective synthesis of the evidence about the incidence of pneumonia in persons with SCI. Incidence was calculated per 100 person-days, and meta-regression was used to evaluate the influence of the clinical setting, the level of injury, the use of mechanical ventilation, the presence of tracheostomy, and dysphagia. For the meta-regression we included 19 studies. The incidence ranged from 0.03 to 7.21 patients with pneumonia per 100 days. The main finding of this review is that we found large heterogeneity in the reporting of the incidence, and we therefore should be cautious with interpreting the results. In the multivariable meta-regression, the incidence rate ratios showed very wide confidence intervals, which does not allow a clear conclusion concerning the risk of pneumonia in the different stages after a SCI. Large longitudinal studies with a standardized reporting on risk factors, pneumonia, and detailed time under observation are needed. Nevertheless, this review showed that pneumonia is still a clinically relevant complication and pneumonia prevention should focus on the ICU setting and patients with complete tetraplegia.
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Furlan D, Deana C, Orso D, Licari M, Cappelletto B, DE Monte A, Vetrugno L, Bove T. Perioperative management of spinal cord injury: the anesthesiologist's point of view. Minerva Anestesiol 2021; 87:1347-1358. [PMID: 34874136 DOI: 10.23736/s0375-9393.21.15753-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Traumatic spinal cord injury (SCI) is one of the most devastating events a person can experience. It may be life-threatening or result in long-term disability. This narrative review aims to delineate a systematic step-wise airways, breathing, circulation and disability (ABCD) approach to perioperative patient management during spinal cord surgery in order to fill some of the gaps in our current knowledge. METHODS We performed a comprehensive review of the literature regarding the perioperative management of traumatic spinal injuries from May 15, 2020, to December 13, 2020. We consulted the PubMed and Embase database libraries. RESULTS Videolaryngoscopy supplements the armamentarium available for airway management. Optical fiberscope use should be evaluated when intubating awake patients. Respiratory complications are frequent in the acute phase of traumatic spinal injury, with an estimated incidence of 36-83%. Early tracheostomy can be considered for expected difficult weaning from mechanical ventilation. Careful intraoperative management of administered fluids should be pursued to avoid complications from volume overload. Neuromonitoring requires investments in staff training and cooperation, but better outcomes have been obtained in centers where it is routinely applied. The prone position can cause rare but devastating complications, such as ischemic optic neuropathy; thus, the anesthetist should take the utmost care in positioning the patient. CONCLUSIONS A one-size fit all approach to spinal surgery patients is not applicable due to patient heterogeneity and the complexity of the procedures involved. The neurologic outcome of spinal surgery can be improved, and the incidence of complications reduced with better knowledge of patient-specific aspects and individualized perioperative management.
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Affiliation(s)
- Davide Furlan
- Department of Medicine (DAME), University of Udine, Udine, Italy
| | - Cristian Deana
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
| | - Daniele Orso
- Department of Medicine (DAME), University of Udine, Udine, Italy
| | - Maurizia Licari
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
| | - Barbara Cappelletto
- Section of Spine and Spinal Cord Surgery, Department of Neurological Sciences, ASUFC University Hospital of Udine, Udine, Italy
| | - Amato DE Monte
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
| | - Luigi Vetrugno
- Department of Medicine (DAME), University of Udine, Udine, Italy - .,Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
| | - Tiziana Bove
- Department of Medicine (DAME), University of Udine, Udine, Italy.,Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
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Hatton GE, Mollett PJ, Du RE, Wei S, Korupolu R, Wade CE, Adams SD, Kao LS. High tidal volume ventilation is associated with ventilator-associated pneumonia in acute cervical spinal cord injury. J Spinal Cord Med 2021; 44:775-781. [PMID: 32043943 PMCID: PMC8477933 DOI: 10.1080/10790268.2020.1722936] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
CONTEXT/OBJECTIVE Pneumonia is the leading cause of death after acute spinal cord injury (SCI). High tidal volume ventilation (HVtV) is used in SCI rehabilitation centers to overcome hypoventilation while weaning patients from the ventilator. Our objective was to determine if HVtV in the acute post-injury period in SCI patients is associated with lower incidence of ventilator-associated pneumonia (VAP) when compared to patients receiving standard tidal volume ventilation. DESIGN Cohort study. SETTING Red Duke Trauma Institute, University of Texas Health Science Center at Houston, TX, USA. PARTICIPANTS Adult Acute Cervical SCI Patients, 2011-2018. INTERVENTIONS HVtV. OUTCOME MEASURES VAP, ventilator dependence at discharge, in-hospital mortality. RESULTS Of 181 patients, 85 (47%) developed VAP. HVtV was utilized in 22 (12%) patients. Demographics, apart from age, were similar between patients who received HVtV and standard ventilation; patients were younger in the HVtV group. VAP developed in 68% of patients receiving HVtV and in 44% receiving standard tidal volumes (P = 0.06). After adjustment, HVtV was associated with a 1.96 relative risk of VAP development (95% credible interval 1.55-2.17) on Bayesian analysis. These results correlate with a >99% posterior probability that HVtV is associated with increased VAP when compared to standard tidal volumes. HVtV was also associated with increased rates of ventilator dependence. CONCLUSIONS While limited by sample size and selection bias, our data revealed an association between HVtV and increased VAP. Further investigation into optimal early ventilation settings is needed for SCI patients, who are at a high risk of VAP.
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Affiliation(s)
- Gabrielle E. Hatton
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Center for Surgical Trials and Evidence-based Practice, HoustonTexas, USA,Corresponding to: Gabrielle E. Hatton, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, 6410 Fannin Street Suite 471, Houston, TX77030, USA; Ph: 713-500-4330, fax: 713-500-0714.
| | - Patrick J. Mollett
- Department of Physical Medicine and Rehabilitation, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Reginald E. Du
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,McGovern Medical School at the University of Texas Health Science Center, HoustonTexas, USA
| | - Shuyan Wei
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Center for Surgical Trials and Evidence-based Practice, HoustonTexas, USA
| | - Radha Korupolu
- Department of Physical Medicine and Rehabilitation, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Charles E. Wade
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Sasha D. Adams
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Lillian S. Kao
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Center for Surgical Trials and Evidence-based Practice, HoustonTexas, USA
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Lee S, Roh SW, Jeon SR, Park JH, Kim KT, Lee YS, Cho DC. A Prognostic Factor for Prolonged Mechanical Ventilator-Dependent Respiratory Failure after Cervical Spinal Cord Injury : Maximal Canal Compromise on Magnetic Resonance Imaging. J Korean Neurosurg Soc 2021; 64:791-798. [PMID: 34420278 PMCID: PMC8435643 DOI: 10.3340/jkns.2020.0346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 02/02/2021] [Indexed: 11/27/2022] Open
Abstract
Objective The period of mechanical ventilator (MV)-dependent respiratory failure after cervical spinal cord injury (CSCI) varies from patient to patient. This study aimed to identify predictors of MV at hospital discharge (MVDC) due to prolonged respiratory failure among patients with MV after CSCI.
Methods Two hundred forty-three patients with CSCI were admitted to our institution between May 2006 and April 2018. Their medical records and radiographic data were retrospectively reviewed. Level and completeness of injury were defined according to the American Spinal Injury Association (ASIA) standards. Respiratory failure was defined as the requirement for definitive airway and assistance of MV. We also evaluated magnetic resonance imaging characteristics of the cervical spine. These characteristics included : maximum canal compromise (MCC); intramedullary hematoma or cord transection; and integrity of the disco-ligamentous complex for assessment of the Subaxial Cervical Spine Injury Classification (SLIC) scoring. The inclusion criteria were patients with CSCI who underwent decompression surgery within 48 hours after trauma with respiratory failure during hospital stay. Patients with Glasgow coma scale 12 or lower, major fatal trauma of vital organs, or stroke caused by vertebral artery injury were excluded from the study.
Results Out of 243 patients with CSCI, 30 required MV during their hospital stay, and 27 met the inclusion criteria. Among them, 48.1% (13/27) of patients had MVDC with greater than 30 days MV or death caused by aspiration pneumonia. In total, 51.9% (14/27) of patients could be weaned from MV during 30 days or less of hospital stay (MV days : MVDC 38.23±20.79 vs. MV weaning, 13.57±8.40; p<0.001). Vital signs at hospital arrival, smoking, the American Society of Anesthesiologists classification, Associated injury with Injury Severity Score, SLIC score, and length of cord edema did not differ between the MVDC and MV weaning groups. The ASIA impairment scale, level of injury within C3 to C6, and MCC significantly affected MVDC. The MCC significantly correlated with MVDC, and the optimal cutoff value was 51.40%, with 76.9% sensitivity and 78.6% specificity. In multivariate logistic regression analysis, MCC >51.4% was a significant risk factor for MVDC (odds ratio, 7.574; p=0.039).
Conclusion As a method of predicting which patients would be able to undergo weaning from MV early, the MCC is a valid factor. If the MCC exceeds 51.4%, prognosis of respiratory function becomes poor and the probability of MVDC is increased.
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Affiliation(s)
- Subum Lee
- Department of Neurosurgery, Trauma Center, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sung Woo Roh
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Ryong Jeon
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Hoon Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyoung-Tae Kim
- Department of Neurosurgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Young-Seok Lee
- Department of Neurosurgery, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Dae-Chul Cho
- Department of Neurosurgery, Trauma Center, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
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Clinical features and prognosis of COVID-19/SARS-CoV-2 infections in persons with spinal cord injury: a review of current literature. Spinal Cord Ser Cases 2021; 7:58. [PMID: 34257266 PMCID: PMC8276211 DOI: 10.1038/s41394-021-00420-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 06/19/2021] [Accepted: 06/21/2021] [Indexed: 12/28/2022] Open
Abstract
Study design Focused literature review. Objectives Objective of the study was to perform a literature search and summarise the clinical features and prognosis of persons with spinal cord injury (SCI) infected with COVID-19 from the published articles. Setting India. Methods PubMed, CENTRAL and MEDLINE were systematically searched using specific keywords. The study assessed 2747 scientific studies involving COVID-19 and SCI for possible inclusion in a meta-analysis of SCI and SARS-COV-2. Studies involving persons with SCI who were tested positive for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in the nasopharyngeal or throat swab polymerase chain reaction were included. Results Out of 2747 articles, 11 articles (206 participants), including six case reports, were included in this review. Fever was the most frequently observed symptom of COVID-19 infection in the SCI population. C-reactive protein (CRP) and lymphocytopenia were common abnormal laboratory parameters. The most common radiological finding in COVID-19 infection was ground glass opacities in lung fields. Prophylactic/therapeutic anticoagulation was given in a significant number of SCI persons infected with COVID-19. Persons with SCI who were diagnosed early showed good outcomes. Conclusions Based on the few studies published on COVID-19 and SCI populations since 2019, this study determined fever, elevated CRP, lymphocytopenia and ground glass opacities, which indicated inflammation, compromised immune response, and lung edema, as the main clinical features of COVID-19 infection in SCI population. Though COVID-19 infection reported an increased number of deaths in few studies, a significant number of SCI populations with positive RT-PCR were treated successfully and discharged at home.
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Cavka K, Fuller DD, Tonuzi G, Fox EJ. Diaphragm Pacing and a Model for Respiratory Rehabilitation After Spinal Cord Injury. J Neurol Phys Ther 2021; 45:235-242. [PMID: 34049339 PMCID: PMC8711094 DOI: 10.1097/npt.0000000000000360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE Cervical spinal cord injury (CSCI) can cause severe respiratory impairment. Although mechanical ventilation (MV) is a lifesaving standard of care for these patients, it is associated with diaphragm atrophy and dysfunction. Diaphragm pacing (DP) is a strategy now used acutely to promote MV weaning and to combat the associated negative effects. Initial reports indicate that DP also may promote neuromuscular plasticity and lead to improvements in spontaneous diaphragm activation and respiratory function. These outcomes suggest the need for reevaluation of respiratory rehabilitation for patients with CSCI using DP and consideration of new rehabilitation models for these patients and their unique care needs. SUMMARY OF KEY POINTS This article discusses the rationale for consideration of DP as a rehabilitative strategy, particularly when used in combination with established respiratory interventions. In addition, a model of respiratory rehabilitation and recovery (RRR) is presented, providing a framework for rehabilitation and consideration of DP as an adjuvant rehabilitation approach. The model promotes goals such as respiratory recovery and independence, and lifelong respiratory health, via interdisciplinary care, respiratory training, quantitative measurement, and use of adjuvant strategies such as DP. Application of the model is demonstrated through a description of an inpatient rehabilitation program that applies model components to patients with CSCI who require DP. RECOMMENDATIONS FOR CLINICAL PRACTICE As DP use increases for patients with acute CSCI, so does the need and opportunity to advance rehabilitation approaches for these patients. This perspective article is a critical step in addressing this need and motivating the advancement of rehabilitation strategies for CSCI patients. (See Video Abstract, Supplemental Digital Content, available at: http://links.lww.com/JNPT/A348).
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Affiliation(s)
- Kathryn Cavka
- Brooks Rehabilitation, Jacksonville, Florida (K.C., G.T., E.J.F.); and Department of Physical Therapy, University of Florida, Gainesville (D.D.F., E.J.F.)
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Wilkerson C, Dailey AT. Spinal Cord Injury Management on the Front Line: ABCs of Spinal Cord Injury Treatment Based on American Association of Neurological Surgeons/Congress of Neurological Surgeons Guidelines and Common Sense. Neurosurg Clin N Am 2021; 32:341-351. [PMID: 34053722 DOI: 10.1016/j.nec.2021.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Spinal cord injury (SCI) affects approximately 54 per 1 million people annually in the United States. Treatment strategies for this patient population focus on initial stabilization and early intervention. The cornerstones of early management are clinical assessment, characterization of the injury, medical optimization, and definitive surgical treatment, including surgical stabilization and/or decompression. This article discusses the important strategies in caring for patients with SCI that are supported with significant literature.
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Affiliation(s)
- Christopher Wilkerson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 North Medical Drive East, Salt Lake City, UT 84132, USA
| | - Andrew T Dailey
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 North Medical Drive East, Salt Lake City, UT 84132, USA.
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Park J, Kang D, Eun SD. Development and pilot testing of novel game-based respiratory rehabilitation exercise devices for patients with tetraplegia. Technol Health Care 2021; 29:1119-1127. [PMID: 34180438 PMCID: PMC8673545 DOI: 10.3233/thc-212860] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND: Individuals with spinal cord injuries (SCI) show restricted breathing patterns with reduced lung volumes and capacities. OBJECTIVE: To improve breathing in such individuals, we aimed to develop breathing exercise devices using a user-centered design (UCD) and then assess the effects of these devices on breathing. METHODS: Patients with SCI were involved in the device development. Preliminary online survey participants were recruited from the community, and interview and pilot test participants were recruited from a patient self-help group. The four UCD phases were repeatedly performed. Users required fun, easy, multi-player, and safe exercise devices. RESULTS: Seven breathing exercise devices were developed, and 10 different game-based exercises were performed. Two individuals participated in a pilot test involving a respiratory rehabilitation exercise program conducted twice weekly for 60 min/session over 8 weeks. Lung function was assessed using a spirometer. Forced vital capacity, forced expiratory volume in 1 s, and vital capacity showed minimal changes, whereas maximum inspiratory and expiratory pressures improved. Participants reported that the exercises were entertaining and that the competitive nature of the game-like exercises encouraged further participation. CONCLUSION: Breathing exercise programs using our developed devices can improve breathing and positively affect the psychological states and sociability of users.
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Affiliation(s)
| | | | - Seon-Deok Eun
- Corresponding author: Seon-Deok Eun, %****␣thc-29-thc212860_temp.tex␣Line␣125␣**** Ministry of Health and Welfare, National Rehabilitation Center, National Rehabilitation Research Institute, Department of Healthcare and Public Health Research, 58, Samgaksan-ro, Gangbuk-gu, Seoul, 01022, Korea. Tel.: +82 2 901 1917; Fax: +82 2 901 1930; E-mail:
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Monden KR, Coker J, Charlifue S, Bennett SJ, Draganich C, Coons D, Marino RJ, Berliner J. Long-Term Follow-Up of Patients With Ventilator-Dependent High Tetraplegia Managed With Diaphragmatic Pacing Systems. Arch Phys Med Rehabil 2021; 103:773-778. [PMID: 33766556 DOI: 10.1016/j.apmr.2021.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/14/2021] [Accepted: 03/16/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To explore participants' experiences after implantation of a diaphragmatic pacing system (DPS). DESIGN Cross-sectional, observational study using self-report questionnaires. SETTING Participants were recruited from 6 Spinal Cord Injury Model System centers across the United States (Craig Hospital, CO; Jefferson/Magee Rehabilitation Hospital, PA; Kessler Rehabilitation Center, NJ; University of Miami, FL; The Shirly Ryan Ability Lab, IL; Shepherd Center, GA). INTERVENTIONS Not applicable. PARTICIPANTS Men and women (N=28) with tetraplegia were enrolled in the study between November 2012 and January 2015. MAIN OUTCOME MEASURES Participants completed self-report questionnaires focused on their DPS usage and mechanical ventilation, as well as their experiences and satisfaction with the DPS. RESULTS DPS is a well-tolerated and highly successful device to help individuals living with spinal cord injury who are dependent on ventilators achieve negative pressure, ventilator-free breathing. A small percentage of participants reported complications, including broken pacing wires and surgery to replace or reposition wires. CONCLUSIONS This study provides insight into the usage patterns of DPS and both the potential negative and positive effects that DPS can have on the life of the user. Knowledge gained from this study can provide a foundation for further discussion about the benefits and potential risks of using a DPS to inform an individual's decision to pursue a DPS implant.
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Affiliation(s)
- Kimberley R Monden
- Research Department, Craig Hospital, Englewood, CO; Department of Rehabilitation Medicine, University of Minnesota Medical School, Minneapolis, MN.
| | | | | | - Stephanie J Bennett
- Research Department, Craig Hospital, Englewood, CO; Department of Psychology, University of Colorado, Denver, CO
| | - Christina Draganich
- Department of Physical Medicine and Rehabilitation, University of Colorado, Anschutz Medical School, Aurora, CO
| | - David Coons
- Rocky Mountain Regional VA Medical Center, Aurora, CO
| | - Ralph J Marino
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Jeffrey Berliner
- Research Department, Craig Hospital, Englewood, CO; CNS Medical Group, Englewood CO
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Teng YD, Zafonte RD. Prelude to the special issue on novel neurocircuit, cellular and molecular targets for developing functional rehabilitation therapies of neurotrauma. Exp Neurol 2021; 341:113689. [PMID: 33745921 DOI: 10.1016/j.expneurol.2021.113689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 03/07/2021] [Indexed: 11/15/2022]
Abstract
The poor endogenous recovery capacity and other impediments to reinstating sensorimotor or autonomic function after adult neurotrauma have perplexed modern neuroscientists, bioengineers, and physicians for over a century. However, despite limited improvement in options to mitigate acute pathophysiological sequalae, the past 20 years have witnessed marked progresses in developing efficacious rehabilitation strategies for chronic spinal cord and brain injuries. The achievement is mainly attributable to research advancements in elucidating neuroplastic mechanisms for the potential to enhance clinical prognosis. Innovative cross-disciplinary studies have established novel therapeutic targets, theoretical frameworks, and regiments to attain treatment efficacy. This Special Issue contained eight papers that described experimental and human data along with literature reviews regarding the essential roles of the conventionally undervalued factors in neural repair: systemic inflammation, neural-respiratory inflammasome axis, modulation of glutamatergic and monoaminergic neurotransmission, neurogenesis, nerve transfer, recovery neurobiology components, and the spinal cord learning, respiration and central pattern generator neurocircuits. The focus of this work was on how to induce functional recovery from manipulating these underpinnings through their interactions with secondary injury events, peripheral and supraspinal inputs, neuromusculoskeletal network, and interventions (i.e., activity training, pharmacological adjuncts, electrical stimulation, and multimodal neuromechanical, brain-computer interface [BCI] and robotic assistance [RA] devices). The evidence suggested that if key neurocircuits are therapeutically reactivated, rebuilt, and/or modulated under proper sensory feedback, neurological function (e.g., cognition, respiration, limb movement, locomotion, etc.) will likely be reanimated after neurotrauma. The efficacy can be optimized by individualizing multimodal rehabilitation treatments via BCI/RA-integrated drug administration and neuromechanical protheses.
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Affiliation(s)
- Yang D Teng
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA; Neurotrauma Recovery Research, Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital Network, Mass General Brigham, and Harvard Medical School, Boston, MA, USA; Spaulding Research Institute, Spaulding Rehabilitation Hospital Network, Boston, MA, USA.
| | - Ross D Zafonte
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA; Neurotrauma Recovery Research, Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital Network, Mass General Brigham, and Harvard Medical School, Boston, MA, USA; Spaulding Research Institute, Spaulding Rehabilitation Hospital Network, Boston, MA, USA.
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Andrade MJ, Quintas FL, Silva AM, Cruz P. Is autonomic dysreflexia a cause of respiratory dysfunction after spinal cord injury? Spinal Cord Ser Cases 2021; 7:4. [PMID: 33468993 PMCID: PMC7815905 DOI: 10.1038/s41394-020-00372-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 11/29/2020] [Accepted: 12/04/2020] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Spinal cord injury (SCI) often leads to impairment of the respiratory system. In fact, respiratory insufficiency is a significant cause of mortality and morbidity following SCI, related to the extent and level of the neurologic injury and its effects on the respiratory muscles (reduction in respiratory muscle strength and fatigue due to a reduction in inspiratory capacity, atelectasis and ineffective coughing). Less commonly recalled is the fact that autonomic dysreflexia (AD) is the result of parasympathetic imbalance. However, AD results from a massive, unrestrained outpouring of norepinephrine from the peripheral sympathetic ganglia. More accurately, the vagal (parasympathetic) response to this sympathetic discharge may have been responsible for the respiratory changes reported. This is not described in medical literature, although breathing difficulty is named as a common symptom and sign. The objective of this report is to describe a clinical case for the first time, that of T4 AIS (American spinal injury association impairment scale) A in which AD leads to acute respiratory insufficiency. CASE REPORT A patient with prior history of spinal cord injury, T4 AIS A, was admitted to the Inpatient Unit to improve her respiratory function and autonomy and to discontinue the ventilation maintained after an episode of pneumonia. The patient developed AD during the rehabilitation programme, namely during hamstring stretching exercises. Besides persistent hypertension, cutaneous rash, hyperhidrosis and light-headedness, the patient was diagnosed with acute respiratory insufficiency, with desaturation and hypercapnia. The patient fully recovered, in terms of the signs and symptoms of AD, with the cessation of noxious stimulation and oxygen administration. DISCUSSION To date, the association between AD and acute respiratory insufficiency has not been described in spinal cord injury or rehabilitation literature. This case draws attention for the first time to the possibility that respiratory insufficiency is one of the signs associated with episodes of AD and highlights the need to look at this possibility.
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Affiliation(s)
- Maria João Andrade
- Spinal Cord Injury Unit, Department of Physical Medicine and Rehabilitation, Hospital Santo António, Medical School, Instituto de Ciências Biomédicas Abel Salazar, Porto University, Porto, Portugal
| | - Filipe Lima Quintas
- Spinal Cord Injury Unit, Department of Physical Medicine and Rehabilitation, Hospital Santo António, Medical School, Instituto de Ciências Biomédicas Abel Salazar, Porto University, Porto, Portugal
| | - André Maia Silva
- Spinal Cord Injury Unit, Department of Physical Medicine and Rehabilitation, Hospital Santo António, Medical School, Instituto de Ciências Biomédicas Abel Salazar, Porto University, Porto, Portugal
| | - Patrícia Cruz
- Spinal Cord Injury Unit, Department of Physical Medicine and Rehabilitation, Hospital Santo António, Medical School, Instituto de Ciências Biomédicas Abel Salazar, Porto University, Porto, Portugal.
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Abstract
Individuals with spinal cord injury (SCI) are at increased risk of respiratory complications during wake and sleep. Sleep-disordered breathing (SDB) is commonly associated with SCI and requires an individualized approach to its management. Respiratory control plays a key role in the pathogenesis of SDB in cervical SCI. Noninvasive ventilation plays an important role in the management of respiratory complications in individuals with SCI acutely and in chronic phases. Positive airway pressure treatment may be effective in eliminating SDB and improving sleepiness symptoms, but adherence to treatment is poor and effect on long-term outcomes is questionable.
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Affiliation(s)
- Asil Daoud
- Department of Medicine, John D. Dingell VA Medical Center, Wayne State University, Detroit Medical Center, 3990 John R St, Detroit, MI 48201, USA; Department of Medicine, Wayne State University, Detroit, MI, USA; Detroit Medical Center, Detroit, MI, USA
| | - Samran Haider
- Department of Medicine, John D. Dingell VA Medical Center, Wayne State University, Detroit Medical Center, 3990 John R St, Detroit, MI 48201, USA; Department of Medicine, Wayne State University, Detroit, MI, USA; Detroit Medical Center, Detroit, MI, USA
| | - Abdulghani Sankari
- Department of Medicine, John D. Dingell VA Medical Center, Wayne State University, Detroit Medical Center, 3990 John R St, Detroit, MI 48201, USA; Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University, 3990 John R, 3-Hudson, Detroit, MI 48201, USA; Ascension Providence Hospital, Southfield, MI, USA.
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Palermo AE, Cahalin LP, Nash MS. A case for inspiratory muscle training in SCI: potential role as a preventative tool in infectious respiratory diseases like COVID-19. Spinal Cord Ser Cases 2020; 6:87. [PMID: 32943611 PMCID: PMC7494979 DOI: 10.1038/s41394-020-00337-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 08/27/2020] [Accepted: 08/31/2020] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Respiratory complications (RC) are a leading cause of death after spinal cord injury (SCI) due to compromised immune function and respiratory muscle weakness. Thus, individuals with SCI are at high risk of developing COVID-19 related RC. Results of a SCI clinical trial showed a supervised respiratory muscle training (RMT) program decreased risk of developing RC. The feasibility of conducting unsupervised RMT is not well documented. Four publications (n = 117) were identified in which unsupervised RMT was performed. Significant improvements in respiratory outcomes were reported in two studies: Maximal Inspiratory and Expiratory Pressure (MIP40% and MEP25%, respectively), Peak Expiratory Flow (PEF9%), seated and supine Forced Vital Capacity (FVC23% and 26%, respectively), and Peak Cough Flow (28%). This review and case report will attempt to show that an inspiratory muscle training (IMT) home exercise program (HEP) is feasible and may prepare the respiratory system for RC associated with COVID-19 in patients with SCI. CASE PRESENTATION A 23-year-old with tetraplegia (P1), history of mechanical ventilation, and hospitalization for RC, completed 27 IMT HEP sessions in one month. MIP and sustained MIP (SMIP) increased from baseline by 28% and 26.5%, respectively. Expiratory volumes and rates also improved (FVC, FEV1, and PEF: 11.7%, 8.3%, and 14.2%, respectively). DISCUSSION The effects of COVID-19 on patients with SCI remains inconclusive, but recent literature and the results of this case suggest that unsupervised IMT is feasible and may limit the severity of RC in patients with SCI who contract COVID-19.
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Affiliation(s)
- Anne E Palermo
- Department of Physical Therapy, The Miami Project to Cure Paralysis, The University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Lawrence P Cahalin
- Department of Physical Therapy, The University of Miami Miller School of Medicine, Miami, FL, USA
| | - Mark S Nash
- The Miami Project to Cure Paralysis, The University of Miami Miller School of Medicine, Miami, FL, USA
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McRae J, Smith C, Emmanuel A, Beeke S. The experiences of individuals with cervical spinal cord injury and their family during post-injury care in non-specialised and specialised units in UK. BMC Health Serv Res 2020; 20:783. [PMID: 32831066 PMCID: PMC7443811 DOI: 10.1186/s12913-020-05659-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 08/14/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Individuals with acute cervical spinal cord injury require specialised interventions to ensure optimal clinical outcomes especially for respiratory, swallowing and communication impairments. This study explores the experiences of post-injury care for individuals with cervical spinal cord injury and their family members during admissions in specialised and non-specialised units in the United Kingdom. METHODS Semi-structured interviews were undertaken with individuals with a cervical spinal cord injury and their family member, focussing on the experience of care across units. Eight people with spinal cord injury levels from C2 to C6, were interviewed in their current care settings. Six participants had family members present to support them. Interviews were audio-recorded and transcribed with data inputted into NVivo for thematic analysis. RESULTS The study identified six themes from the participant interviews that highlighted different experiences of care in non-specialised and specialised settings. A number of these were related to challenges with the system, whilst others were about the personal journey of recovery. The themes were titled as: adjustment, transitions, "the golden opportunity", "when you can't eat", communication, and "in the hands of the nurses and doctors". CONCLUSIONS Whilst participants reported being well cared for in non-specialised units, they felt that they did not receive specialist care and this delayed their rehabilitation. Participants were dependent on healthcare professionals for information and care and at times lost hope for recovery. Staff in non-specialised units require training and guidance to help provide support for those with dysphagia and communication difficulties, as well as reassurance to patients and families whilst they wait for transfer to specialised units.
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Affiliation(s)
- Jackie McRae
- Faculty of Health, Social Care and Education, Kingston and St Georges University of London, London, UK
| | - Christina Smith
- Division of Psychology and Language Science, University College London, London, WC1N 1PF UK
| | - Anton Emmanuel
- Division of Medicine, University College London, London, WC1E 6JF UK
| | - Suzanne Beeke
- Division of Psychology and Language Science, University College London, London, WC1N 1PF UK
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Mu Z, Zhang Z. Risk factors for tracheostomy after traumatic cervical spinal cord injury. J Orthop Surg (Hong Kong) 2020; 27:2309499019861809. [PMID: 31319757 DOI: 10.1177/2309499019861809] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To determine the risk factors for the need of tracheostomy after cervical spinal cord injury (CSCI) at the acute stage. METHODS The authors retrospectively reviewed 294 patients with acute traumatic CSCI in Xinqiao Hospital between 2012 and 2016 and analyzed the factors postulated to increase the risk for tracheostomy, including patient's age, neurological impairment scale grade and level, smoking history, combined injury, and surgical intervention. Logistic regression analysis was used to identify independent risk factor for the need of tracheostomy. RESULTS Of 294 patients, 52 patients received tracheostomy (17.7%). The factor identified by demographics and outcomes were smoking history, cause of injury, neurological impairment scale grade and level, and combined dislocation. A multiple logistic regression model demonstrated that age of 60 years older, combined facet dislocation, C4 level high, and the American Spinal Injury Association (ASIA) A and B scale were predictive of need for tracheostomy on 95% occasions. CONCLUSION The high age of 60 years, combined facet dislocation, C4 level high, and ASIA A and B scale are indispensable to predict the need for tracheostomy in patients with CSCI at the acute stage.
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Affiliation(s)
| | - Zhengfeng Zhang
- Department of Orthopedics, Xinqiao Hospital, Third Military Medical University, Chongqing, China
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Gautam C, Kaur J, Singh H. Effect of Upper Limb Proprioceptive Neuromuscular Facilitation with Resistance Training on Respiratory Muscle Strength in Quadriplegics: A Randomized Controlled Trial. EXERCISE MEDICINE 2020. [DOI: 10.26644/em.2020.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Jang WH, Lee SB, Kim DW, Lee YH, Uhm YJ, Yang SW, Kim JH, Kim JB. ICT-Based Health Care Services for Individuals with Spinal Cord Injuries: A Feasibility Study. SENSORS 2020; 20:s20092491. [PMID: 32354052 PMCID: PMC7249337 DOI: 10.3390/s20092491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/15/2020] [Accepted: 04/24/2020] [Indexed: 11/16/2022]
Abstract
In the Republic of Korea, 90.5% of those living with spinal cord injury (SCI) are faced with medical complications that require chronic care. Some of the more common ones include urinary tract infections, pressure sores, and pain symptomatology. These and other morbidities have been recognized to deteriorate the individual's health, eventually restricting their community participation. Telerehabilitation, using information and communication technology, has propelled a modern-day movement in providing comprehensive medical services to patients who have difficulty in mobilizing themselves to medical care facilities. This study aims to verify the effectiveness of health care and management in the SCI population by providing ICT-based health care services. We visited eight individuals living with chronic SCI in the community, and provided ICT-based health management services. After using respiratory and urinary care devices with the provision of home visit occupational therapy, data acquisition was achieved and subsequently entered into a smart device. The entered information was readily accessible to the necessary clinicians and researchers. The clients were notified if there were any concerning results from the acquired data. Subsequently, they were advised to follow up with their providers for any immediate medical care requirements. Digital hand-bike ergometers and specialized seating system cushions are currently in development. The ICT-based health care management service for individuals with SCI resulted in a favorable expected level of outcome. Based on the results of this study, we have proposed and are now in preparation for a randomized clinical trial.
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Affiliation(s)
- Wan-ho Jang
- Department of Occupational Therapy, The Graduate School, Yonsei University, Wonju 26493, Korea; (W.-h.J.); (D.-w.K.); (Y.-h.L.)
| | - Seung-bok Lee
- Clinical Team, Yonsei Enabling Science and Technology Research Center, Wonju 26493, Korea; (S.-b.L.); (S.-w.Y.)
| | - Dong-wan Kim
- Department of Occupational Therapy, The Graduate School, Yonsei University, Wonju 26493, Korea; (W.-h.J.); (D.-w.K.); (Y.-h.L.)
| | - Yun-hwan Lee
- Department of Occupational Therapy, The Graduate School, Yonsei University, Wonju 26493, Korea; (W.-h.J.); (D.-w.K.); (Y.-h.L.)
| | - Yun-jeong Uhm
- Department of Ergonomic Therapy, The Graduate School of Health and Environment, Yonsei University, Wonju 26493, Korea;
| | - Seung-wan Yang
- Clinical Team, Yonsei Enabling Science and Technology Research Center, Wonju 26493, Korea; (S.-b.L.); (S.-w.Y.)
| | - Jeong-hyun Kim
- Usability Center, Yonsei Enabling Science Technology Research Center, Wonju 26493, Korea;
| | - Jong-bae Kim
- Department of Occupational Therapy, College of Health Science, Yonsei University, Wonju 26493, Korea
- Correspondence:
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Critical Care Ultrasound Should Be a Priority First-Line Assessment Tool in Neurocritical Care. Crit Care Med 2020; 47:833-836. [PMID: 30870190 DOI: 10.1097/ccm.0000000000003712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Jensen VN, Alilain WJ, Crone SA. Role of Propriospinal Neurons in Control of Respiratory Muscles and Recovery of Breathing Following Injury. Front Syst Neurosci 2020; 13:84. [PMID: 32009911 PMCID: PMC6978673 DOI: 10.3389/fnsys.2019.00084] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 12/16/2019] [Indexed: 12/20/2022] Open
Abstract
Respiratory motor failure is the leading cause of death in spinal cord injury (SCI). Cervical injuries disrupt connections between brainstem neurons that are the primary source of excitatory drive to respiratory motor neurons in the spinal cord and their targets. In addition to direct connections from bulbospinal neurons, respiratory motor neurons also receive excitatory and inhibitory inputs from propriospinal neurons, yet their role in the control of breathing is often overlooked. In this review, we will present evidence that propriospinal neurons play important roles in patterning muscle activity for breathing. These roles likely include shaping the pattern of respiratory motor output, processing and transmitting sensory afferent information, coordinating ventilation with motor activity, and regulating accessory and respiratory muscle activity. In addition, we discuss recent studies that have highlighted the importance of propriospinal neurons for recovery of respiratory muscle function following SCI. We propose that molecular genetic approaches to target specific developmental neuron classes in the spinal cord would help investigators resolve the many roles of propriospinal neurons in the control of breathing. A better understanding of how spinal circuits pattern breathing could lead to new treatments to improve breathing following injury or disease.
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Affiliation(s)
- Victoria N. Jensen
- Neuroscience Graduate Program, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Warren J. Alilain
- Spinal Cord and Brain Injury Research Center, University of Kentucky College of Medicine, Lexington, KY, United States,Department of Neuroscience, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Steven A. Crone
- Division of Neurosurgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States,Division of Developmental Biology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States,Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, United States,*Correspondence: Steven A. Crone
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McCaughey EJ, Butler JE, McBain RA, Boswell-Ruys CL, Hudson AL, Gandevia SC, Lee BB. Abdominal Functional Electrical Stimulation to Augment Respiratory Function in Spinal Cord Injury. Top Spinal Cord Inj Rehabil 2019; 25:105-111. [PMID: 31068742 DOI: 10.1310/sci2502-105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background: Functional electrical stimulation (FES) is the application of electrical pulses to a nerve to achieve a functional muscle contraction. Surface electrical stimulation of the nerves that innervate the abdominal muscles, termed abdominal FES, can cause the abdominal muscles to contract, even when paralysed after spinal cord injury. As the abdominal muscles are the major expiratory muscles, and commonly partially or completely paralysed in tetraplegia, abdominal FES offers a promising method of improving respiratory function for this patient group. Objective: The aim of the article is to provide readers with a better understanding of how abdominal FES can be used to improve the health of the spinal cord-injured population. Methods: A narrative review of the abdominal FES literature was performed. Results: Abdominal FES can achieve an immediate effective cough in patients with tetraplegia, while the repeated application over 6 weeks of abdominal FES can improve unassisted respiratory function. Ventilator duration and tracheostomy cannulation time can also be reduced with repeated abdominal FES. Conclusion: Abdominal FES is a noninvasive method to achieve functional improvements in cough and respiratory function in acute and chronically injured people with tetraplegia. Potential practical outcomes of this include reduced ventilation duration, assisted tracheostomy decannulation, and a reduction in respiratory complications. All of these outcomes can contribute to reduced morbidity and mortality, improved quality of life, and significant potential cost savings for local health care providers.
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Affiliation(s)
- E J McCaughey
- Neuroscience Research Australia, Randwick, Australia.,School of Medical Sciences, University of New South Wales, Kensington, Australia
| | - J E Butler
- Neuroscience Research Australia, Randwick, Australia.,School of Medical Sciences, University of New South Wales, Kensington, Australia
| | - R A McBain
- Neuroscience Research Australia, Randwick, Australia.,School of Medical Sciences, University of New South Wales, Kensington, Australia.,Prince of Wales Hospital, Randwick, Australia
| | - C L Boswell-Ruys
- Neuroscience Research Australia, Randwick, Australia.,School of Medical Sciences, University of New South Wales, Kensington, Australia.,Prince of Wales Hospital, Randwick, Australia
| | - A L Hudson
- Neuroscience Research Australia, Randwick, Australia.,School of Medical Sciences, University of New South Wales, Kensington, Australia
| | - S C Gandevia
- Neuroscience Research Australia, Randwick, Australia.,School of Medical Sciences, University of New South Wales, Kensington, Australia.,Prince of Wales Hospital, Randwick, Australia
| | - B B Lee
- Neuroscience Research Australia, Randwick, Australia.,School of Medical Sciences, University of New South Wales, Kensington, Australia.,Prince of Wales Hospital, Randwick, Australia
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Racca F, Vianello A, Mongini T, Ruggeri P, Versaci A, Vita GL, Vita G. Practical approach to respiratory emergencies in neurological diseases. Neurol Sci 2019; 41:497-508. [PMID: 31792719 PMCID: PMC7224095 DOI: 10.1007/s10072-019-04163-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 11/15/2019] [Indexed: 02/06/2023]
Abstract
Many neurological diseases may cause acute respiratory failure (ARF) due to involvement of bulbar respiratory center, spinal cord, motoneurons, peripheral nerves, neuromuscular junction, or skeletal muscles. In this context, respiratory emergencies are often a challenge at home, in a neurology ward, or even in an intensive care unit, influencing morbidity and mortality. More commonly, patients develop primarily ventilatory impairment causing hypercapnia. Moreover, inadequate bulbar and expiratory muscle function may cause retained secretions, frequently complicated by pneumonia, atelectasis, and, ultimately, hypoxemic ARF. On the basis of the clinical onset, two main categories of ARF can be identified: (i) acute exacerbation of chronic respiratory failure, which is common in slowly progressive neurological diseases, such as movement disorders and most neuromuscular diseases, and (ii) sudden-onset respiratory failure which may develop in rapidly progressive neurological disorders including stroke, convulsive status epilepticus, traumatic brain injury, spinal cord injury, phrenic neuropathy, myasthenia gravis, and Guillain-Barré syndrome. A tailored assistance may include manual and mechanical cough assistance, noninvasive ventilation, endotracheal intubation, invasive mechanical ventilation, or tracheotomy. This review provides practical recommendations for prevention, recognition, management, and treatment of respiratory emergencies in neurological diseases, mostly in teenagers and adults, according to type and severity of baseline disease.
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Affiliation(s)
- Fabrizio Racca
- Department of Anaesthesia and Intensive Care, Sant'Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Andrea Vianello
- Respiratory Pathophysiology Division, University of Padua, Padua, Italy
| | - Tiziana Mongini
- Neuromuscular Center, Department of Neurosciences, University of Turin, Turin, Italy
| | - Paolo Ruggeri
- Unit of Pneumology, Department BIOMORF, University of Messina, Messina, Italy
| | - Antonio Versaci
- Intensive Care Unit, AOU Policlinico "G. Martino", Messina, Italy
| | - Gian Luca Vita
- Nemo Sud Clinical Centre for Neuromuscular Disorders, Messina, Italy
| | - Giuseppe Vita
- Nemo Sud Clinical Centre for Neuromuscular Disorders, Messina, Italy. .,Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
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Abstract
OBJECTIVES To describe the current state of the art regarding management of the critically ill trauma patient with an emphasis on initial management in the ICU. DATA SOURCES AND STUDY SELECTION A PubMed literature review was performed for relevant articles in English related to the management of adult humans with severe trauma. Specific topics included airway management, hemorrhagic shock, resuscitation, and specific injuries to the chest, abdomen, brain, and spinal cord. DATA EXTRACTION AND DATA SYNTHESIS The basic principles of initial management of the critically ill trauma patients include rapid identification and management of life-threatening injuries with the goal of restoring tissue oxygenation and controlling hemorrhage as rapidly as possible. The initial assessment of the patient is often truncated for procedures to manage life-threatening injuries. Major, open surgical procedures have often been replaced by nonoperative or less-invasive approaches, even for critically ill patients. Consequently, much of the early management has been shifted to the ICU, where the goal is to continue resuscitation to restore homeostasis while completing the initial assessment of the patient and watching closely for failure of nonoperative management, complications of procedures, and missed injuries. CONCLUSIONS The initial management of critically ill trauma patients is complex. Multiple, sometimes competing, priorities need to be considered. Close collaboration between the intensivist and the surgical teams is critical for optimizing patient outcomes.
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