Higher MAP targets in acute spinal cord injury show no neurologic benefit, more complications

Editor's Note

Early blood pressure augmentation did not improve neurologic outcomes and was linked to more complications, according to a JAMA Network study published on September 18. In this multicenter randomized clinical trial at 13 US trauma centers, 92 adults with acute cervical or thoracic spinal cord injury were assigned to augmented mean arterial pressure (MAP) targets greater than 85 to 90 mm Hg or conventional targets greater than 65 to 70 mm Hg for up to 7 days.

At 6 months, there were no differences between groups in American Spinal Injury Association motor or sensory score changes. Among survivors with follow-up, upper extremity motor, lower extremity motor, and total sensory outcomes were statistically similar across strategies. Mortality and other secondary outcomes also did not differ.

Safety signals favored conventional targets. The augmented group had higher noncardiovascular organ dysfunction scores at day 3 and day 6, required longer mechanical ventilation on average 9.44 vs 3.78 days, and experienced more respiratory complications 78% vs 39%, including higher rates of pneumonia and pulmonary edema. Four protocol nonadherence events occurred, and blood pressure targets were temporarily adjusted in several cases.

The trial was underpowered due to early termination and losses to follow-up, which the authors noted limits definitive inference. Mean MAP in the conventional arm generally exceeded 75 mm Hg, which may also have narrowed between-group differences. Still, the pattern of no neurologic benefit with more harms calls the practice of routine augmentation into question.

The article situates these findings against guideline uncertainty. A 2013 recommendation endorsed maintaining MAP 85 to 90 mm Hg for 7 days based on low-quality evidence, while more recent guidance suggests 75 to 80 mm Hg for 3 to 7 days with similarly weak support. Observational data have hinted at benefit from higher pressures, but this randomized trial did not corroborate those gains.

For perioperative and critical care teams, the results support prioritizing avoidance of hypotension without defaulting to high-dose vasopressors that can drive pulmonary complications and resource use. The authors call for adequately powered trials to identify which patients, if any, benefit from augmentation and to clarify mechanisms of potential harm.