Why methylprednisolone for spinal cord injury

References A. Rubiano, N. Carney, R. Chesnut, and J. S—S, Hurlbert, M. Hadley, B. Walters et al. Chikuda, H. Yasunaga, K.

Takeshita et al. Hall and J. Bracken, M. Shepard, W. Collins et al. CD, View at: Google Scholar M. Fehlings, J. Wilson, and N. Eck, D. Nachtigall, S. Humphreys, and S. E—E, Schroeder, B. Kwon, J. Eck, J. Savage, W. Hsu, and A. Druschel, K. Schaser, and J. Teles, J. Cabrera, K. Riew, and A.

Goldberg, W. Rothfus, Z. Deeb et al. Kates, D. Atkinson, and M. View at: Google Scholar G. Tang and G. Hsu, M. Tran, and A. Vaquero, M. Zurita, S. Tait, S. Saadoun, B. Bell, and M. Reyes-Alva, R. Franco-Bourland, A. Martinez-Cruz, I. Grijalva, I. Madrazo, and G. S14—S17, Yoon, Y. Kim, and W. Basso, M. Beattie, and J. Maikos and D. Hawkins and R. Nesic, J.

Lee, Z. Ye et al. Matsumoto, T. Tamaki, M. Kawakami, M. Yoshida, M. Ando, and H. Shepard, T. Holford et al. View at: Google Scholar J. Sloka and M. Pereira, L. Costa, A. Cabrita et al. Boldin, J. Raith, F.

Fankhauser, C. Haunschmid, G. Schwantzer, and F. Conclusions: There is insufficient evidence to support the use of high-dose methylprednisolone within eight hours following an acute closed spinal cord injury as a treatment standard or as a guideline for treatment. Methylprednisolone, prescribed as a bolus intravenous infusion of 30 mg per kilogram of body weight over fifteen minutes within eight hours of closed spinal cord injury, followed 45 minutes later by an infusion of 5.

There is insufficient evidence to support extending methylprednisolone infusion beyond 23 hours if chosen as a treatment option. Abstract Background: A systematic review of the evidence pertaining to methylprednisolone infusion following acute spinal cord injury was conducted in order to address the persistent confusion about the utility of this treatment. Charts were reviewed for a predetermined list of complications. A total of patient charts were reviewed; patients were included in the study.

MPSS was administered in 59 cases. In 34 In 13 Among the patients with ASCI, 20 Among the patients without ASCI, 10 Patients receiving steroids for pediatric ASCI were significantly more likely to experience complications than patients not receiving steroids.

T reatment options for acute spinal cord injury ASCI are limited. Methylprednisolone sodium succinate MPSS has been studied as a pharmacological adjunct that may be given postinjury to improve neurological recovery.

MPSS possesses a variety of neuroprotective effects, including inhibition of lipid peroxidation, calcium influx, and ischemia and antiinflammatory activity. Criticisms of the NASCIS trials included study designs, data quality, statistical analysis, interpretation, and conclusions. Subsequent studies have raised concerns regarding the safety of this therapy in light of the results from the NASCIS trials and the known complications of high-dose steroids.

If the patient was transferred from an outside facility and MPSS administration had already been initiated, this would be completed per guidelines, even in the presence of a negative MRI study. The dose and administration instructions remained the same during the time of the study. The unusual administration requirements for this therapy were found to present challenges with prescribing, given the various order entry systems in place at our institution, dispensing by the pharmacy, and administration and monitoring by nursing personnel.

To the best of our knowledge, no studies currently exist describing problems associated with prescribing or administering high-dose MPSS therapy.

To address this gap in the literature, we studied the medication use process for this treatment at our institution. Our specific aims were to determine 1 adherence in ordering and delivery of medications according to the guideline and 2 the types and frequency of complications.

This was a retrospective, cross-sectional cohort chart review of pediatric trauma cases involving patients who presented to our institution from January 1, , through September 30, Our institution is a bed academic tertiary-care facility located in southwestern Ohio.

The trauma center is an American College of Surgeons—designated Level 1 pediatric center and admits, on average, trauma patients annually. The institutional Trauma Registry was queried for patients who met the standard inclusion criteria for ICD-9 injury codes — Paper charts were requested for patients treated prior to implementation of the EMR system.

Charts were manually reviewed by the trauma nurse educator and emergency medicine clinical pharmacist for the following data elements: steroid treatment, including guideline adherence; gastrointestinal GI ulcer prophylaxis; and a predetermined list of side effects attributed to steroid use. Descriptive frequencies were generated for patient demographics, guideline adherence, and complications. Statistical comparisons between cohorts i. During the year study period, 20, injured patients were treated at our institution.

Applying our inclusion criteria and the aforementioned ICD-9 codes yielded patient records. Of the included charts for patients 0—17 years of age, 69 Of the patients with ASCI, 36 Of those without ASCI, 23 8. This resulted in a total of 59 patients Inclusion and exclusion summary.

The average age of all patients included in this study was The average length of stay was 5. More of the patients were male than female, and the majority were white.

No significant differences in demographics were noted between patients receiving steroids and those not receiving steroids. No significant differences were noted in demographics between patients with and without ASCI. Given the complicated nature of ordering and administration of this therapy, the accuracy of the ordering process was investigated. The 3 components of the medication order investigated included drug, dose, and route.

As a composite outcome, the therapy was ordered correctly for the purposes of this study in The medication was ordered correctly as MPSS for 53 Four 6. The correct dose was ordered per guideline for 41 The route of administration was correctly ordered as intravenous for 58 Of the 59 cases in which patients received MPSS, the order was placed correctly in 34 Due to lack of medication administration record MAR data, 6 Of the patients ordered MPSS, 38 In the group without ASCI, 10 The frequency of complications in the pediatric patients who received steroids is shown in Table 2.

Table 3 shows the frequency of complications among patients with and without ASCI and with and without steroid exposure. Patients receiving steroids experienced the highest numbers of complications per individual, as many as 6 complications in a patient with ASCI and 9 complications in a patient without ASCI. The n value given under each column head is the total number of patients in that group column who experienced a complication. Table 4 shows the types and frequency of specific complications in patients with and without ASCI and with and without steroid exposure.

On average, pediatric patients receiving steroids had 2. ASCI is a critical injury in the pediatric and adult populations, with the potential for long-term disability for the patient and significant costs for the family and health care community. It is only natural that health care providers would explore and implement therapies at the bedside early in the management of suspected ASCI with the goal of reducing long-term morbidity.

After thorough evaluation, the multidisciplinary consensus was to incorporate clinical concern and patient status as factors in decision making for administration of MPSS for ASCI for pediatric patients presenting to our institution, following the institutional guideline. However, the complex nature of the high-dose MPSS protocol, with multiple inclusion criteria and a complicated dosing regimen, contributes to the unlikeliness that the health care team will implement the protocol exactly as it was intended, especially when it is applied infrequently.

Of the 69 patients ultimately diagnosed with ASCI, only 8 Similar problems with inaccurate administration of this protocol in adults have been shown. In a study by Lee et al. Based on the findings of poor compliance with the protocol, a worksheet was created to assist staff with timing of administration of the bolus and continuous infusion of MPSS.

GI prophylaxis was also incorporated into the worksheet as a reminder to order in the EMR. An electronic health record order-set was also created once the EMR system was implemented , which automated the dose and timing in the EMR. Given the infrequent or uncommon nature of ASCI in our pediatric population, it makes sense for providers to look for algorithms, guidelines, or protocols to simplify and prescribe care.

However, there is innate danger when applying these protocols if a patient does not meet inclusion criteria. Additionally, while protocols are useful to standardize care for patients with similar conditions, Chang et al.