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Kim M, Firek M, Coimbra BC, Allison-Aipa T, Zakhary B, Coimbra R. Impact of Cardiac Pacemaker Implantation in Patients With Acute Traumatic Cervical Spinal Cord Injury. Am Surg 2024; 90:2577-2583. [PMID: 38686651 DOI: 10.1177/00031348241250041] [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: 05/02/2024]
Abstract
BACKGROUND Cardiac pacemaker implantation may be indicated in patients with refractory bradycardia following a cervical spinal cord injury (CSCI). However, evidence about the impact of this procedure on outcomes is lacking. We planned a study to assess whether the implantation of a pacemaker would decrease mortality and hospital resource utilization in patients with CSCI. METHODS Adult patients with CSCI in the Trauma Quality Improvement Program (TQIP) database between 2016 and 2019 were retrospectively analyzed. Patients were divided into "pacemaker" and "non-pacemaker" groups, and their baseline characteristics and clinical outcomes were analyzed. RESULTS A total of 6774 cases were analyzed. The pacemaker group showed higher in-hospital rates of cardiac arrest, myocardial infarction, and longer duration of mechanical ventilation and ICU stay than the non-pacemaker group. Nevertheless, pacemaker placement was associated with a significant decrease in mortality (4.2% vs 26.0%, P < .01). CONCLUSIONS Patients with CSCI requiring a pacemaker placement had better survival than those treated without a pacemaker. Pacemaker implantation should be highly considered in patients who develop refractory bradycardia after CSCI.
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Affiliation(s)
- Maru Kim
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System, Moreno Valley, CA, USA
- Department of Trauma Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Matthew Firek
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System, Moreno Valley, CA, USA
| | - Bruno Cammarota Coimbra
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System, Moreno Valley, CA, USA
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Timothy Allison-Aipa
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System, Moreno Valley, CA, USA
| | - Bishoy Zakhary
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System, Moreno Valley, CA, USA
| | - Raul Coimbra
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System, Moreno Valley, CA, USA
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Lim-Hing K, Massetti J, Pajoumand M, Gupta S, Jenkins R, Hassan M, Paganelli P, Parikh G, Chang WT, Schwartzbauer G, Stein D, Badjatia N. Impact of Enteral Albuterol on Bradycardic Events After Acute Cervical Spinal Cord Injury. Neurocrit Care 2021; 36:840-845. [PMID: 34845597 DOI: 10.1007/s12028-021-01384-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 10/19/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Acute cervical spinal cord injury (ACSCI) is commonly complicated by spinal shock, resulting in hemodynamic instability characterized by bradycardia and hypotension that can have fatal consequences. Current guidelines recommend the use of intravenous beta and dopamine agonists, such as norepinephrine and dopamine, respectively. We sought to determine whether enteral albuterol would be a safe and feasible treatment for bradycardia without an increase in the occurrence of known side effects of albuterol in patients with ACSCI. METHODS A retrospective review of patients with ACSCI admitted to an intensive care unit at a level I trauma center and treated with enteral albuterol was conducted. Patients were excluded for the following reasons: pure beta blocker use prior to injury, concurrent use of pacemaker, age of less than 18 years, or age more than 75 years. As part of the standard of care, all patients underwent mean arterial pressure (MAP) augmentation to reach a goal of greater than 85 mm Hg during the first 7 days post injury. All eligible patient charts were reviewed for demographic characteristics, daily minimum and maximum heart rate and MAP, and concomitant vasoactive medication use. Bradycardia and tachycardia were defined as heart rate less than 60 beats per minute (bpm) and greater than 100 bpm, respectively. Factors found to be associated with bradycardia on univariate analysis were entered into a multivariable generalized estimating equation analysis to determine factors independently associated with bradycardia during the study period. RESULTS There were 58 patients with cervical ASCI (age 45 ± 18 years, 76% men) admitted between January 1, 2016, and December 31, 2017, that met the study criteria. The mean time to initiation of albuterol was 1.5 ± 1.7 days post injury, with a duration of 9.3 ± 4.5 days and a mean daily dosage of 7.8 ± 4.5 mg. Bradycardia was observed in 136 of 766 patient days (17%). There were a few episodes of hyperglycemia (1%) and tachycardia (3%), but no episodes of hypokalemia. In a multivariable analysis, female sex (P = 0.006) and American Spinal Cord Injury Association grade A, B, or C (P < 0.001) were associated with a higher risk of developing bradycardia, whereas dosage of albuterol (P = 0.009) and norepinephrine use (P = 0.008) were associated with a lower risk of developing bradycardia. CONCLUSIONS Albuterol administration in ASCI is a safe and feasible treatment for bradycardia, given that no significant side effects, such as hyperglycemia, hypokalemia, or tachycardia, were observed. The administration of enteral albuterol was well tolerated and, in a dose-dependent manner, associated with a lower occurrence of bradycardia. Further prospective trials for the use of enteral albuterol after SCI are warranted.
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Affiliation(s)
- Krista Lim-Hing
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA. .,Department of Pharmacy, University of Maryland Medical Center, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Jennifer Massetti
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA.,Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mehrnaz Pajoumand
- Department of Pharmacy, University of Maryland Medical Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shailvi Gupta
- Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ryne Jenkins
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mubariz Hassan
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Paxton Paganelli
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gunjan Parikh
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Wan-Tsu Chang
- Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gary Schwartzbauer
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA.,Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Deborah Stein
- Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Neeraj Badjatia
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA.,Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
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Viskin S, Havakuk O, Antzelevitch C, Rosso R. Theophylline: The forgotten antiarrhythmic drug… now for malignant early repolarization. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 41:441-443. [PMID: 29148055 DOI: 10.1111/pace.13239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 10/22/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Sami Viskin
- Tel Aviv Medical Center and Sackler School of Medicine, Tel Aviv University, Israel
| | - Ofer Havakuk
- Tel Aviv Medical Center and Sackler School of Medicine, Tel Aviv University, Israel
| | | | - Raphael Rosso
- Tel Aviv Medical Center and Sackler School of Medicine, Tel Aviv University, Israel
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Rollstin A, Carey MC, Doherty G, Tawil I, Marinaro J. Oral albuterol to treat symptomatic bradycardia in acute spinal cord injury. Intern Emerg Med 2016; 11:101-5. [PMID: 26438078 DOI: 10.1007/s11739-015-1324-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 09/16/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Amber Rollstin
- Department of Emergency Medicine, MSC11 6025, University of New Mexico School of Medicine, 1 University of New Mexico, Albuquerque, NM, 87131-0001, USA.
| | - Michael C Carey
- Department of Anesthesia and Critical Care Medicine, MSC 10 6000, University of New Mexico School of Medicine, 2211 Lomas Blvd NE, Albuquerque, NM, 87106, USA.
| | - Gloria Doherty
- Inpatient Providers and Pulmonary Services, University of New Mexico School of Medicine, 2211 Lomas Blvd NE, Albuquerque, NM, 87106, USA.
| | - Isaac Tawil
- Department of Emergency Medicine, MSC11 6025, University of New Mexico School of Medicine, 1 University of New Mexico, Albuquerque, NM, 87131-0001, USA.
| | - Jonathan Marinaro
- Department of Emergency Medicine, MSC11 6025, University of New Mexico School of Medicine, 1 University of New Mexico, Albuquerque, NM, 87131-0001, USA.
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Wood GC, Boucher AB, Johnson JL, Wisniewski JN, Magnotti LJ, Croce MA, Swanson JM, Boucher BA, Fabian TC. Effectiveness of pseudoephedrine as adjunctive therapy for neurogenic shock after acute spinal cord injury: a case series. Pharmacotherapy 2013; 34:89-93. [PMID: 23918202 DOI: 10.1002/phar.1335] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
STUDY OBJECTIVE To evaluate the effectiveness of pseudoephedrine as adjunctive therapy for neurogenic shock in patients with acute spinal cord injury (SCI). DESIGN Case series. SETTING Academic medical center. PATIENTS Thirty-eight patients admitted to the trauma intensive care unit between September 2005 and October 2012 with an acute SCI and who received more than 1 day of pseudoephedrine for one or more of the following: treatment of bradycardia (heart rate ≤ 50 beats/min), treatment of hypotension (systolic blood pressure < 90 mm Hg), or were receiving intravenous vasopressor support. MEASUREMENTS AND MAIN RESULTS The effect of adjunctive pseudoephedrine (PSE) was categorized as a success if vasopressors were discontinued after the initiation of PSE or improvement in the number of episodes of bradycardia was noted after the initiation of PSE as evidenced by decreased use of atropine. The effect of pseudoephedrine was categorized as a failure if it did not meet one of the criteria for success. The effect of pseudoephedrine was categorized as inconclusive if there were confounding factors such as vasopressors being restarted for another indication after initial discontinuation. Pseudoephedrine was successful in 31/38 (82%) patients, failed in 2/38 (5%) patients, and had inconclusive results in 5/38 (13%) patients. The mean ± SD time to successful weaning of intravenous vasopressors was 7 ± 7 days. Daily maximum pseudoephedrine doses ranged from 60-720 mg. Mean ± SD duration of pseudoephedrine therapy was 32 ± 23 days (range 2-135 days), with 64.5% of surviving patients discharged while receiving pseudoephedrine. CONCLUSION These data suggest that pseudoephedrine is an effective adjunctive therapy in facilitating the discontinuation of intravenous vasopressors and/or atropine in patients with acute SCI with neurogenic shock, although patients will typically require long durations of therapy.
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Affiliation(s)
- G Christopher Wood
- Department of Clinical Pharmacy, College of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee
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Sadaka F, Naydenov SK, Ponzillo JJ. Theophylline for bradycardia secondary to cervical spinal cord injury. Neurocrit Care 2011; 13:389-92. [PMID: 20878263 DOI: 10.1007/s12028-010-9454-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Spinal cord injury (SCI) is a devastating disease process that can occur as a consequence of motor vehicle collisions, falls, or other traumatic injuries. Persistent bradycardia was found to be universally present in all high cervical SCI patients. Limited data exists to suggest the most effective therapy for the bradycardia associated with high cervical SCI. Treatment includes atropine, epinephrine, dopamine, and even implantable cardiac pacemakers, all of which have their risks and side effects. There are no prospective studies to evaluate methylxanthines for the treatment of bradycardia secondary to cervical SCI. METHODS We report on four patients in whom Theophylline was successfully used enterally as a second line agent to treat bradycardia secondary to cervical SCI. We also reported on two patients in whom Theophylline was successfully used as a first line agent. Bradycardia resolved in all patients RESULTS Theophylline levels were below toxic levels in all of the patients and no side effects from theophylline were observed. CONCLUSIONS Theophylline's use via enteral route can successfully and safely treat SCI-related bradycardia, and may help avoid the long term use of inotropic and chronotropic infusions and pacemakers and their associated risks and complications. We strongly recommend further studies to establish the role of this agent as a first line therapy in this specific patient population. Optimal dosing and duration of therapy will also need to be established.
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Affiliation(s)
- Farid Sadaka
- St. John's Mercy Medical Center, St. Louis University, 621 S. New Ballas Rd, suite 4006B, St. Louis, MO 63141, USA.
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Moranville MP, Mieure KD, Santayana EM. Evaluation and management of shock States: hypovolemic, distributive, and cardiogenic shock. J Pharm Pract 2010; 24:44-60. [PMID: 21507874 DOI: 10.1177/0897190010388150] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Shock states have multiple etiologies, but all result in hypoperfusion to vital organs, which can lead to organ failure and death if not quickly and appropriately managed. Pharmacists should be familiar with cardiogenic, distributive, and hypovolemic shock and should be involved in providing safe and effective medical therapies. An accurate diagnosis is necessary to initiate appropriate lifesaving interventions and target therapeutic goals specific to the type of shock. Clinical signs and symptoms, as well as hemodynamic data, help with initial assessment and continued monitoring to provide adequate support for the patient. It is necessary to understand these hemodynamic parameters, medication mechanisms of action, and available mechanical support when developing a patient-specific treatment plan. Rapid therapeutic intervention has been proven to decrease morbidity and mortality and is crucial to providing the best patient outcomes. Pharmacists can provide their expertise in medication selection, titration, monitoring, and dose adjustment in these critically ill patients. This review will focus on parameters used to assess hemodynamic status, the major causes of shock, pathophysiologic factors that cause shock, and therapeutic interventions that should be employed to improve patient outcomes.
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Affiliation(s)
- Michael P Moranville
- University of Chicago Medical Center, Department of Pharmaceutical Services, Chicago, IL 60637, USA.
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McMahon D, Tutt M, Cook AM. Pharmacological management of hemodynamic complications following spinal cord injury. Orthopedics 2009; 32:331. [PMID: 19472960 DOI: 10.3928/01477447-20090502-07] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Damage from spinal cord injury (SCI) may be complicated by concomitant hemodynamic alterations within hours to months of the initial insult. Neurogenic shock, symptomatic bradycardia, autonomic dysreflexia, and orthostatic hypotension are specific conditions occurring commonly with SCI. Early recognition and appropriate management of each disorder may minimize secondary injury to the cord, avert systemic complications, and help alleviate patient discomfort.
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Affiliation(s)
- Deanna McMahon
- University of Kentucky HealthCare, Lexington, Kentucky 40536-0293, USA
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