Hemodynamic Management and Vasopressor Selection in Acute Spinal Cord Injury

Introduction: Acute spinal cord injury (SCI) often results in severe neurological deficits, with hemodynamic instability contributing to secondary ischemic damage. Beyond surgical decompression, maintaining adequate mean arterial pressure (MAP) is crucial to optimize spinal cord perfusion (SCP) and oxygenation. Vasopressor therapy is frequently used to achieve hemodynamic stability, but optimal MAP targets and vasopressor selection remain debated. This review examines current guidelines and evidence on MAP management and vasopressor use in SCI, focusing on their impact on SCP and neurological outcomes.

Methods: A literature review was conducted focusing on updated guidelines, clinical studies, and expert opinions on MAP management and vasopressor therapy in acute SCI. The review evaluated the effects of vasopressors such as norepinephrine, dopamine, phenylephrine, and dobutamine on hemodynamic stability and SCP. The benefits and risks associated with each vasopressor, as well as the role of individualized patient factors, were assessed to provide a comprehensive overview of current practices and emerging targets, such as spinal cord perfusion pressure (SCPP).

Results: Recent evidence highlights the importance of maintaining adequate MAP to support SCP and reduce secondary ischemic injury following acute SCI. Studies suggest a MAP target of 75-80 mmHg as the lower limit and 90-95 mmHg as the upper limit for 3-7 days post-injury can improve neurologic outcomes. Norepinephrine is commonly the preferred vasopressor due to its balanced effects on peripheral vascular resistance and spinal cord perfusion pressure (SCPP), with fewer side effects and a 2-3 mmHg increase in SCPP compared to dopamine. Further evidence supports the idea that directly targeting SCPP, rather than just MAP, may improve outcomes, though the invasive nature of SCPP monitoring limits its widespread use.

Conclusion : MAP management and vasopressor use in SCI are critical for improving neurological outcomes. The choice of vasopressor should be individualized based on the patient’s hemodynamic profile and clinical needs to balance efficacy and adverse effects, with norepinephrine often favored for its balanced effects. Continued research is needed to refine vasopressor protocols, explore the role of SCPP, and develop evidence-based strategies that enhance SCI recovery while minimizing risks.