Non-Surgical Management and Weaning of Patients with Cervical Spinal Cord Injury

Publication: 10/11/2016  
Next review: 28/12/2023  
Clinical Guideline
CURRENT 
ID: 4782 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2021  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Non-Surgical Management and Weaning of Patients with Cervical Spinal Cord Injury.

Introduction

Patients with acute cervical spinal cord injury (SCI) present complex clinical challenges. These injuries may result in motor and sensory deficits and also in cardiovascular and respiratory perturbations. Increased attention to critical care support has led to improved survival and recovery in many patients . Managing the processes of care with clinical guidelines has shown to be effective in reducing the incidence and severity of respiratory complications, the duration of mechanical ventilation and ICU length of stay. 2

If you require any further information please contact the spinal injuries link nurses within Leeds Teaching Hospitals NHS Trust (LTHT) or the specialist spinal injuries centres within our referral network;

Yorkshire Regional Spinal Injuries Centre -
Pinderfields General Hospital,
Wakefield
0844 8118110

Princess Royal Spinal Injuries and Neuro-Rehabilitation Centre,
Northern General Hospital,
Sheffield
0114 2715644

Neurosurgical Intensive Care
Leeds General Infirmary
Spinal Injuries Link Nurses
01133927402/3

An online referral to the spinal injuries unit should be made within 24 hours of admission by the patients’ medical team: www.scireferrals.nhs.uk

An ASIA score should be completed on all patients with spinal cord injury.

Management Chapters:

  1. Neck stabilisation
  2. Airway and Respiratory Support
  3. Humidification, Nebulisers and Management of thick secretions
  4. Sialorrhoea
  5. Tracheostomy Tube Exchanges
  6. Posture
  7. Physiotherapy
  8. Weaning From Mechanical Ventilation
  9. Cuff Deflation and Speaking Valve Use
  10. Neurogenic shock
  11. Autonomic Dysreflexia
  12. Thromboprophylaxis
  13. Haemoglobin
  14. Gastrointestinal Support
  15. Gastric Ulcer Protection
  16. Bowel regime
  17. Bladder care
  18. Repositioning, Turning and Skin Assessment
  19. Pain Management
  20. Pharmacological Interventions for Spasticity
  21. Psychological and emotional support
  22. Reactive depression / low mood
  23. Night sedation / Delirium
  24. Financial Support

Please Note: The Management chapters listed are not in any sequential or priority order

1. Neck Stabilisation

Stabilisation of a patient’s neck with a confirmed or suspected spinal cord injury is essential. This includes the use of a neck collar or spinal board and immobilisation of the patient. A log roll should be performed until the neck is cleared following CT or the patient has had definitive internal fixation.

Please Follow MASCIP guidelines for moving and handling patients with acute or suspected spinal cord injuries: https://www.mascip.co.uk/wp-content/uploads/2015/02/MASCIP-SIA-Guidelines-for-MH-Trainers.pdf

Please ensure the medical team have completed The Initial Spinal Management of Sedated and Ventilated Trauma Patients algorithm for all LTHT patients that have confirmed or suspected spinal cord injury (Appendix A) or the following link:
http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=5038

The major indicator for early surgical intervention is to restore and preserve function. The indicators for surgery that is within the first 24 hours may include; evidence of neurological involvement, cord compression, penetrating wounds of the spinal cord from surrounding structures and bone fragments within the spinal canal.

Please note patients with certain degenerative changes such as Ankylosing Spondylitis may not be able to wear a collar. This should be clearly documented.

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2. Airway and Respiratory Support

Patients with lesions below the level of C5 are generally able to ventilate adequately, unless they have superimposed chest problems. Flaccid Paralysis of the intercostal muscles in high lesions result in paradoxical movement of the chest wall. The degree of respiratory compromise correlates with the level of injury with a proportional reduction in lung volume for every level of injury one ascends.3

It is advisable to document respiratory frequency, oxygen saturations and vital capacity on a regular basis at least for the first 72 hours. Patients with spinal cord injury at C5 or above have the potential to develop a gradual deterioration of the respiratory function. In these patients regular monitoring of pH, PCO2 and neurological level will help to determine the need for assisted ventilation.4 Trend in transcutaneous CO2 measurement can also help identify need for respiratory support. For more Oxygen guidance follow link http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=1979

Paralysis of the abdominal muscles prevents effective coughing and clearance of chest secretions. Respiratory physiotherapy, breathing exercises and assisted coughing should be commenced at the earliest opportunity (see section 7).

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3. Humidification, Nebulisers and Management of thick secretions

Oxygen with adequate humidification of an appropriate temperature should be provided to all patients. Sodium chloride 0.9% can be used to improve mucociliary transport and act as a mild mucolytic. http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=2454
(nebuliser guidelines)

Thickening/thick secretions should be treated with oral Carbocysteine, 750mg TDS, or, if there is a problem with absorption, nebulised N-acetyl-cysteine 2mLs (400mg) mixed with 2mLs sodium chloride 0.9% TDS-QDS. See nebuliser guidelines above for further advice.

In some circumstances nebulised hypertonic sodium chloride 7% may also be used as a mucolytic (Prescribed as RESP-EASE on eMEDs).

Clinical evidence of bronchospasm requires the use of nebulised bronchodilator therapy, e.g. salbutamol 2.5mg QDS.

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4. Sialorrhoea

A high salivary load due to reduced ability to swallow may be a risk factor for aspiration pneumonia during the tracheostomy weaning process. A common initial treatment for high salivary load would be transdermal hyoscine patch (1mg/72 hours).

Antimuscarinic agents can induce blurred vision, constipation, urinary retention and drowsiness and may also lead to thickening of bronchial secretions. If this occurs a reduced dose (such as prescribing a half hyoscine patch) can be tried.

An alternative to hyoscine (second line antimuscarinic), glycopyrronium bromide (glycopyrrolate) 200micrograms/1ml solution for injection can be used as a continuous subcutaneous infusion. This should be prescribed on a continuous subcutaneous infusion chart at 600micrograms/24 hours with doses increasing up to 1.2mg/24 hours if needed.

In some cases, as an alternative to hyoscine, glycopyrronium bromide (glycopyrrolate) 200micrograms/1ml solution for injection solution can be used orally (via NG/PEG) however this has limited bioavailability. This is at a 1mg BD-TDS dosing which can be titrated up (to 2mgTDS) or down. The side effect profiles of all antimuscarinic agents are similar.

A second line treatment to be considered is injection of botulinum toxin type A (Dysport or Botox) into the submandibular and/or parotid glands (via ultrasound) which can be given in addition to, or as an alternative to, antimuscarinic agents. Prescribing and administration of botulinum toxin type A is restricted to specialists therefore please contact the Acute Neuro-rehabilitation Team for further advice (through Switchboard).

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5. Tracheostomy Tube Exchanges

To minimise granuloma formation, tracheostomy tubes should be changed every 4 weeks. Additionally, tracheostomy tubes should be changed every month to reduce biofilm accumulation. This is similar for all patients with a tracheostomy i.e. there are no special recommendations because the patient has a SCI.

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6. Posture

Contrary to usual practice in intensive care where there is evidence that, to minimise aspiration rates, patients should be nursed at 30°, the physiology of SCI (improved lung volumes, better peak expiratory flow etc.) favours nursing patients flat. Therefore, the goal should be to minimise the duration where patients are sat up.5,18
All patients should be nursed flat as tolerated. If patients are to be sat up higher than 15 degrees then an abdominal binder is recommended.6 Whenever the patient is lying flat the binder can be removed. If the patient shows signs of central cord syndrome (proportionally greater weakness in upper limbs compared to lower limbs) and/or improving respiratory function then management in supine is not required

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7. Physiotherapy

Daily respiratory assessment - This should be performed at least once a day by a physiotherapist in the acute phase.

If there is evidence of any of the following:

  1. Altered breath sounds or reduced lung volumes
  2. Episodes of desaturation (<92% or agreed parameters)
  3. An increase in respiratory rate (>25 or agreed parameters)
  4. Evidence of active chest infection (e.g. increase temperature, increase in secretion load, rising infective markers),
  5. Changes on chest X-Ray,

then treat with manual hyperinflation/cough assist alongside alternate side lying, expiratory vibrations and suction. It may be appropriate to take a more prophylactic approach if the patient is considered at risk of deteriorating especially in the acute phase as incidence of pneumonia is 40-50%.19

Mechanical insufflation – exsufflation

Mechanical insufflation – exsufflation or ‘cough assist’ has been shown to significantly increase FVC, FEV1 and PEF in SCI patients whilst reducing infections, especially when coupled with chest wall manual techniques and assisted cough.20,21,22

This can be provided using a variety of devices and should be considered for use multiple times daily. In the event of desaturation during treatment O2 should be entrained at the mask/ tracheostomy end of the circuit with a flow <15 litres O2 (Note. It is unsafe to entrain O2 while using the Emerson Cough Assist machine). The initial use of the Cough Assist must be performed by a physiotherapist to assess the patient’s tolerance off O2 and the initial settings they will require. Pressures should be started low to ensure patient tolerance and then can be increased until they are at an effective level. Pressures <+/- 40cmH2O can be safely used. Consideration should be given to increasing the insufflation to exsufflation ratio to improve cough effectiveness with some patients.
For patients requiring regular prophylactic treatment a cough assist prescription can be completed, allowing competent members of the nursing staff to administer treatment with the clearway cough assistor.

Please note: evidence shows that IPPB (the ‘bird’) has no short or long term effects on lung function following SCI. Its role in secretion clearance has not been examined.23,24

Suction

If there is difficulty clearing secretions with closed suction, consider open suction as this may provide better access, though may de-recruit if PEEP dependent.

Assisted Cough

An assisted cough or ‘abdominal thrust’ is a manual technique where the hands are used to apply an inwards and upwards force to the abdomen so that the diaphragm is forcibly pushed upwards in order to increase expiratory flow. This must be coordinated with the patient’s attempted cough.
The amount of force required to provide an effective assisted cough is often underestimated. If available, a second person can brace and restrict the movements of the ribcage or perform expiratory vibrations to further augment this technique. Precautions include rib fractures, surgical wounds and abdominal distension.25

Mobilisations

Daily limb mobilisation is required to prevent soft tissue shortening and loss of joint range which can affect long term function. This can also help with the on-going assessment and management of hypersensitivity and spasticity. Physiotherapists should ensure that each acute patient has a full range of daily mobilisations and provide positioning advice within the limitations of any accompanying injury.26

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8. Weaning From Mechanical Ventilation

Weaning implies the reduction in ventilator provided support, until a patient can breathe without the assistance of a mechanical device.
In SCI patients, the challenge comes from neuromuscular weakness/paralysis. Weaning is unlikely to be successful during active parenchymal pathology (e.g. infection, resolving lung contusions or significant pleural effusions). Therefore, as a precondition to weaning, active parenchymal pathology should have either fully resolved or be resolving.
Level and severity of SCI will dictate the impact on diaphragmatic function and the likelihood of weaning from mechanical ventilation. Complete C2 – unlikely to wean. Complete C3-4 – Possibility of weaning. Complete C5 – Likely to wean. There may be possibility of weaning with incomplete lesions at any level, though tracking oedema may limit this in the acute phase.29 Lower cervical and thoracic injuries may also impact on weaning due to weakness in intercostal and abdominal muscle activity.

Preconditions to Weaning

  1. FiO2 < 40% with SaO2 92-96% - a low FiO2 implies an absence of parenchymal pathology which is a necessary precondition before weaning can be considered.
  2. Cardiovascular stability.
  3. Clear Chest X-Ray or resolving Chest X-Ray changes.
  4. No active chest infection or in the presence of a proven chest infection, an identified pathogen with microbiological sensitivities and the patient receiving appropriate antibiotic therapy.
  5. Suitable for on-going support via a BiPAP machine (i.e. the patient no longer needs full mechanical ventilation) and their level of support has been reduced to:
    1. PEEP - ideally 5, but no more than 8. (A requirement for PEEP values much above physiological levels implies on-going problems with oxygenation and by association, parenchymal disease).
    2. Pressure Support - 15cm H20 or less.
    3. Respiratory Rate - < 30 per minute.

The preferred method of weaning is ‘progressive ventilator free weaning’ or ‘sprint weaning.’ This entails having a patient fully established on a pressure supported mode of ventilation e.g. BiPAP or CPAP /PS via a ventilator or NIV device and then progressively ‘training’ the patient to breath for longer periods off mechanical assistance - either with low or high flow humidified O2 via a T-piece or tracheostomy mask. High levels of CPAP in isolation may be contraindicated in patients with poor expiratory muscle function due to the risk of fatigue, increasing FRC and CO2 retention.

Once the preconditions for weaning have been met, the next stage before a full programme of ‘Sprint’ weaning can commence is to establish the patient on BiPAP for a minimum of 12 hours. Despite the theoretical equivalence between the same levels of PEEP and pressure support on different ventilators, often patients do not convert easily from one machine to another. Therefore, once the decision to convert from one type of respiratory support device to another has occurred patients may (although this is not inevitable) need to build up their tolerance on the new BiPAP device over a number of days (e.g. 6 hours on the new device for the first day, 12 hours next day etc.). Units who have access to Maquet ventilators for both level 3 and level 2 beds may wish to conduct sprint weaning directly from these units in the NIV mode.

Once fully established on BiPAP, the settings (EPAP/IPAP) should be reduced to:

  • Lowest attainable PEEP value (whilst maintaining at least physiological PEEP)
  • Pressure support above PEEP 10-12 cm H2O
    The usual settings are IPAP +15, EPAP +5.

At this stage, the ‘Sprint’ Weaning algorithm can be used. (Appendix 4)

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9. Cuff Deflation and Speaking Valve Use

For all spinal cord injured patients the ability to communicate is paramount to rehabilitation and reintegration. Cuff deflation can be achieved either on or off ventilation. Not only does this enable speech but also reduces micro-aspiration, restores laryngeal and pharyngeal reflexes leading to resumption of safe swallowing. There is however a risk of passive aspiration especially if the patient has poor laryngeal reflexes. To mitigate aspiration suction regularly while the cuff is down. Cuff deflation should be assessed for by a competent Physiotherapist or Speech and Language Therapist (SLT).

Off ventilator cuff deflation during sprinting for fast weaning patients should be considered. Trials of cuff deflation and finger occlusion by a competent practitioner to assess upper airway patency and airflow should be completed prior to use of speaking valves. Episodes of cuff deflation without the speaking valve should be considered if upper airway airflow is inadequate prior to consideration of tracheostomy downsize. Repeating this over 1-2 days can often lead to successful occlusion and speaking valve use without the need for tube downsize as oedema and previously pooled secretions settle.

On ventilator cuff deflation should be considered for slow weaners - but only in the absence of chest infection and not at the expense of further ventilator weaning. Ventilator settings should be adjusted to NIV mode allow for the resultant leak and may require an increase in pressure support.

The use of a speaking valve introduces an element of physiological PEEP which may improve respiratory mechanics and reduce the development of atelectasis. However, In some cases it may increase work of breathing. Many patients develop increased leaks when asleep, requiring partial or full cuff inflation in order to achieve adequate ventilation. The speaking valve should also be removed overnight for safety. (Adapted from NWCCN SCI Weaning Guidelines)

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10. Neurogenic Shock

Neurogenic shock describes the hemodynamic changes resulting from a sudden loss of autonomic tone due to spinal cord injury. It is commonly seen when the level of the injury is above T6. Spinal shock, on the other hand, refers to loss of all sensation below the level of injury and is not circulatory in nature.

Cardiovascular instability should be anticipated in all patients with a SCI due to disturbances of the autonomic nervous system. Neurogenic shock can occur immediately after injury and take four to six weeks to subside. Main symptoms include hypotension, bradycardia, poikilothermia and oliguria. A person with a SCI will have lifelong hypotension and bradycardia.7

Hypotension occurs due to passive dilation of the vascular network below the level of injury. Significant drops in blood pressure can result in poor perfusion to vital organs and the spinal cord, resulting in secondary injury (i.e. worsening of the spinal cord injury or a failure to see any recovery of function with time) and ischemia. Initial management should therefore be to monitor blood pressure trends and an intention to correct hypotension if necessary. Vasopressors may be required to sustain vital organ perfusion. These must be prescribed by a doctor and administered within critical care with appropriate monitoring, typically an arterial line. There is Class 3 evidence to suggest an elevated mean arterial pressure over 85-90 mmHg results in independently improved outcomes. We therefore recommend treating patients with cervical SCI with norepinephrine for 5-7 days after injury to maintain MAP 85-90mmHG.27

Hypotension in patients with neurogenic shock is likely due to vasodilation and will generally not respond to fluid challenge alone. Therefore, it is not advisable to give excessive fluid boluses as single first line treatment for significantly low blood pressure. In the resuscitation setting, any patient with significant trauma may be hypovalemic.7

In the longer term patient (beyond 7 days from injury) once noradrenaline (or an equivalent vasoconstrictor) has been or is being weaned off, suitable blood pressure targets should be set, remembering that lifelong hypotension is a feature of SCI. However, troublesome hypotension but more importantly symptomatic orthostatic hypotension (OH) can be managed with oral midrodine. There is level 2 evidence that midrodine may be effective in reducing OH which in turn can improve patient’s functional tolerance to being seated etc.28

Bradycardia is caused by reflex vagal activity; this may not require treatment unless it is directly affecting blood pressure. If clinically indicated the patient may require chemical intervention determined by medical staff. Very high lesions are associated with the need for permanent pacemakers.

Poikilothermia (the inability to regulate temperature) is caused by passive dilation of the vascular network below the level of injury. It is recommended that all patients with a SCI in the acute phase should have rectal probe thermometer monitoring.7 The paralysed section of the body will quickly adopt the temperature of the local environment, and can quickly become hypothermic or hyperthermic, depending on locality or time of year. Consider warming gradually either using blankets or a bare hugger if the core temperature is cool.8

Oliguria is common in the first 72 hours post spinal cord injury due to poor renal perfusion as a direct result of new hypotension. This will subside after a few days however, SCI patients have higher risks of urinary retention therefore all patients with confirmed SCI should have a size 16 long term catheter inserted on admission and will likely need this for life.

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11. Autonomic Dysreflexia (AD)

AD is the term used to describe the paralysed body’s autonomic response to painful (noxious) stimuli perceived below the level of injury (LOI). The sympathetic nervous system responds to these pain signals by the vasoconstriction of blood vessels throughout the paralysed areas of the body, resulting in gross hypertension and bradycardia.7 As a result, there is pallor and dry skin below the LOI (vasoconstriction), with flushing (vasodilatation), sweating and piloerection above the LOI. Bradycardia is a reflex response to the rise in SBP (baroreceptor and parasympathetic reflex). Nasal congestion occurs due to engorgement of the nasal mucosa and the patient may also experience a sense of dread, anxiety, headaches secondary to the rise in SBP. Unchecked, it can cause myocardial ischaemia, arrhythmias including atrial fibrillation, but more importantly seizures, haemorrhagic strokes and death. SBP can exceed 300 mm Hg.9

AD usually occurs 2-3 months’ post injury but can happen sooner. Remembering that the resting SBP of a patient with a high SCI may be low, a recorded SBP of 120-140 mm Hg could be pathological. The higher the LOI, the greater the risk, but any lesion at or above T6 can be complicated with AD. It is almost universally found, to some degree, in lesions above C6.
The commonest trigger is bladder problems in around 90% of cases, followed by bowel issues in 8% of cases e.g. constipation, haemorrhoids, anal fissures etc. (Appendix 2).

Treatment:

Non-pharmacological

  • Sit patient upright, position legs in a dependent position, remove binder, TEDs, loosen clothes, etc. to decrease hypertension.
  • Assess for noxious stimuli cause of AD, begin with urinary system / bladder distension. If patient has an indwelling catheter, check for urinary flow, overfilled bag, or kinks in tubing. If an indwelling urinary catheter is not in place then please catheterise patient according to LTHT guidelines. http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=200
    A bladder scan may be done to help support the aetiology if unsure.
  • If symptoms persist, assess bowel status.
  • Other noxious stimuli include: pressure ulcer or treatment for them, other skin irritants, wrinkled sheets, ingrown toenail, sitting on bump such as wallet, or other item in the rear pocket, VTE, menstrual cramps, labour, other reproductive issues, constrictive clothing, pain, surgical and diagnostic procedures, fractures, gastro-duodenal stress ulcers. Consider the use of analgesia if painful stimuli cannot be removed.

Closely monitor patient throughout the episode, checking and recording BP regularly. Notify medic of episode.9

Pharmacological

  • GTN - Administer one spray of glyceryl trinitrate (GTN) 400 micrograms Nitrolingual Pump Spray (up to 3 doses can be given in 30 minutes). Or if spray is unavailable, place half GTN tablet (300 micrograms) under tongue, or apply one 5 mg/24 hours GTN Transdermal Patch to chest or upper arm (patch should be removed as soon as hypertension resolves).
    Monitor BP; if little or no effect in 5 to 10 minutes, administer a second spray or other half tablet of GTN under tongue. Be cautious when administering GTN spray or tablet as sudden hypotension may result.
    If BP remains elevated or rises rapidly intravenous medication may be indicated - see below.
  • If GTN spray, tablets or patch are unavailable, or contraindicated an alternative (short-acting) antihypertensive agent should be used. Seek urgent advice from the medical team and pharmacist regarding suitable drug availability and/or advice from Critical Care if the use of IV antihypertensives is required.

Please see link for monitoring, cautions etc: https://bnf.nice.org.uk/drug/glyceryl-trinitrate.html#monitoringRequirements.
An acute episode of AD can lead to an increased susceptibility to further episodes due to excess circulating catecholamines. These may be precipitated by activities which would not normally do so, such as performing muscle stretches, bowel care, or other activities. The patient must be alerted to this possibility and monitored appropriately for 48 to 72 hours. During this time invasive procedures should be kept to a minimum.9

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12. Thromboprophylaxis

Without prophylaxis, patients with acute spinal cord injury (SCI) have the highest incidence of DVT among all hospitalised patients. Pulmonary embolism is the third leading cause of death in this patient group.10 Patients that present with signs and symptoms of VTE (DVT & PE) should be investigated and managed following the trust guidelines: http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?id=3962#1

The trust VTE risk assessment form should be completed for all acute SCI patients on admission. Patients without a high risk of bleeding should be commenced on thromboprophylaxis, in the form of low molecular weight heparin (LMWH),10 please refer to LTHT Thromboprophylaxis Guidelines for Critically Ill Patients for current dose and drug of choice:
http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=2035

Consider dose adjustments for extremes of weight as per Trust guidelines http://www.leedsformulary.nhs.uk/docs/2.8.1LMWHdosingatextremesofbodyweight.pdf

LMWH should be commenced as soon as possible after admission, once primary haemostasis has been achieved.10 Patients should be re-assessed for VTE and bleeding risk at 24-48 hours and whenever their clinical situation changes.

Single prophylaxis is not recommended. In addition to LMWH, either graded full length compression stockings or calf compression devices (e.g. Flowtron boots) should be used.

LMWH should continue until discharge from hospital rehabilitation.

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13. Haemoglobin

Transfuse any weaning patient whose haemoglobin is less than 70g/L.11 Any patient in whom weaning is problematic, for example; failure to progress, obvious fatigue despite an appropriate pace of weaning, should probably have their haemoglobin targeted within the 80-100g/L range. There is no evidence for any benefit of haemoglobin levels above 100g/L. This is a census view which takes into account respiratory medicine opinion.

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14. Gastrointestinal Support

Feeding as per out of hours protocol is normal practice, however, Paralytic ileus is common in spinal shock. There is a risk of vomiting/aspiration. Ileus usually occurs immediately in thoraco-lumbar injuries but can be delayed for anything up to 48 hours in cervical injuries. Abdominal distension may impede breathing by splinting the diaphragm. Gastric dilatation may occur even if bowel sounds are present. Therefore close observation for abdominal distension and listening to the abdomen for presence of bowel sounds is essential.15 If the medical team feel risk of ileus outweighs nutrition then this decision should be medical led on a patient by patient basis.

Following this all patients are fed by the NG route until assessed by speech and language therapist (if appropriate). If a prolonged ileus is preventing adequate calorific intake via the NG route, this should trigger early consideration for post-pyloric feeding e.g. NJ or PEJ feeding. In rare circumstances TPN should be considered.
Follow LTHT guidelines for Enteral Feeding: http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=1452#8

Gastric aspirates should be measured according to LTHT guidance (see link above). Advice regarding prokinetic therapy can also be found on this link. Prokinetics should be reviewed as soon as enteral absorption is established.

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15. Gastric Ulcer Protection

All patients should receive gastric protection with a proton pump inhibitor (PPI) from admission. Follow LTHT guidelines for Stress Ulcer Prophylaxis in Adult Critical Care:
http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=4762.

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16. Bowel Regime

Patients with spinal cord injury or neurogenic conditions may have neurogenic bowel dysfunction, which often means they depend on routine interventional bowel care. It is essential to determine what sensation and anal tone patients with spinal cord injuries have in order to provide the right treatment; this will involve performing Digital Rectal examination (DRE) +/- Digital rectal stimulation (DRS) +/- Manual evacuation (ME). As per LTHT Guidelines for digital rectal stimulation and manual evacuation of faeces in adults:
http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=1481

Follow the appropriate algorithm for either reflexic or areflexic bowel (Appendix 3).

Some patients with SCI above T6 are particularly susceptible to the potentially life threatening condition autonomic dysreflexia (AD). AD can be caused by non-adherence to a patient’s usual bowel routine or during or following interventional bowel care. For all these patients, bowel care is essential for their health and dignity - as outlined by NHS improvement patient safety alert 2018.13

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17. Bladder Care

The bladder is flaccid during spinal shock and therefore it is important to avoid over distension as this can have an adverse effect on the patients long term management. Over distension can also cause AD, therefore; all patients with SCI should be managed with a urethral catheter on free drainage. Urine output should be monitored hourly until the patient is stable.7 Please note urine output may be minimal due to increased production of ADH hormone following initial trauma therefore urine output should not always be used as an indicator for volume replacement.7

For guidance on catheterisation and catheter management please see the LTHT guidelines on Urinary Catheterisation of Male and Female Patients:
http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=200

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18. Repositioning, Turning and Skin Assessment

The risk of developing pressures following a spinal cord injury is high due to a combination of factors; these include a lack of motor/sensory function, nutrition, hydration and skin cleansing immediately following soiling or perspiration. Therefore all patients are to have their skin assessed, evaluated and documented as per LTHT protocol using the Purpose T assessment, SSKIN document and Pressure Ulcer Prevention/Management Bundle:
http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=1984

Where clinical condition allows patients must have their positioned changed 2 hourly and a full skin assessment must be completed every 4 hours.14 Extra care must be taken to check for pressure damage, especially underneath abdominal binders, neck collars and other medical devices.

Regular and routine turning not only relieves pressure but also moves static fluid within the paralysed body by reducing the risk of other complications (HAP, UTI, VTE + gastric ulceration). The majority of unstable spinal injury patients will be a full spinal turn, often referred to as a LOG ROLL, this requires 5 staff. Any patient requiring full spinal turns should not be sat up or have their legs elevated by the bed please ‘lock’ (where possible) the features on a bed that do this. Please refer to the LTHT guidelines for the Initial Management of Sedated and Ventilated Trauma Patients:
http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=5038

Positioning:

Head: Until instructed by the medical team (either after spinal fixation or once cleared by CT/MRI) patients with unstable spinal injuries should be log rolled and therefore should have an Aspen collar in situ and sand bags either side of the head at all times. No pillow should be placed under the patients head as this alters spinal alignment.
Side Lying: Patients can be positioned on their side using 3 pillows of similar thickness. The first pillow should rest parallel to the body, start at the shoulders and finish at the base of the spine. The second and third pillow will sit on top of one another and also run parallel to the body, starting just below the buttocks and finish behind the patients calf/ankle. This pillow position ensures the patients spine and leg position is closest to that of the natural curve of the spine. Please Follow MASCIP guidelines for guidance on this: www.mascip.co.uk/wp-content/uploads/2015/02/MASCIP-SIA-Guidelines-for-MH-Trainers.pdf
Legs: When a patient is lying on their back each leg should be elevated with a pillow to achieve a natural bend at the hip and knee.
Feet: To prevent foot drop please liaise with physiotherapy team to ensure foot splints have been ordered, prior to this a pillow against a foot board (bed end) can be used.
Arms: Arms should be elevated from the elbow to hand, with elbows positioned away from the body. Position pillows underneath the arm so it finishes at the elbow joint.
Hands: Hands should have a natural bend (tenodesis); this can be achieved by using crepe bandages into the patients grip (until hand splints are available). The wrist should also be positioned with a slight curve.

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19. Pain Management

Nociceptive pain should be treated according to the WHO pain ladder (e.g. oral paracetamol, followed by the addition of non-steroidal anti-inflammatory agents, weak opiates e.g. codeine or tramadol, and then stronger opiates such as morphine, oxycodone, trans-dermal fentanyl). When prescribing opiates consider gastric protection and checking of renal function. Also, if opiates are prescribed then it is important to consider when doses are required for breakthrough pain and side effects such as constipation.

Neuropathic pain should be treated by commencing gabapentin. Initially 300 mg once daily on day 1, then 300 mg twice daily on day 2, then 300 mg 3 times a day on day 3, alternatively initially 300 mg 3 times a day on day 1, then increased in steps of 300 mg every 2–3 days in 3 divided doses, adjusted according to response; maximum 3.6 g per day. Pregabalin is an option if gabapentin not tolerated.

Consideration should also be given to commencing amitriptyline at night, 10-25 mg initially, with dose titration according to response (doses above 75mg are rarely of further benefit). The acute in-reach rehabilitation medicine teams at LGI and SJUH can review patients and advise on pain management and referral to the chronic pain service can also be considered.

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20. Pharmacological Interventions for Spasticity

Once the flaccidity of spinal shock has resolved then general spasticity becomes increasingly more common post SCI. Physical therapy (e.g. positioning to increase muscle length, passive stretches, weight bearing and muscle strengthening) aims to prevent and diminish spasticity, but generalised spasticity (i.e. increased tone, tendon hyper-reflexia and clonus, and exaggerated extension reflexes) may need pharmacological intervention. Nociceptive drive from pain, skin breakdown, constipation and urine retention are common drivers of spasticity and should be routinely assessed for if considering pharmacological intervention. Rehabilitation medicine involvement, usually from the in-reach teams at LGI and SJUH, should be routinely sought when pharmacological interventions are being considered and treatment decisions should always be made as part of an MDT process of neuro-rehabilitation professionals.

Severe localised spasticity is commonly treated with local injections of botulinum toxin. Assessments for and administration of botulinum toxin should only be undertaken by someone with appropriate expertise and the intended administrator of the injections should be named clearly on the Emeds prescription.

Severe painful spasms can be treated initially with diazepam (GABA-A agonist) 2mg tds with careful dose titration to a maximum of 60mg per day in rare circumstances. Diazepam should be used with care as its potential for sedation (especially associated with hypercapnia) is clearly undesirable in association with weaning and it may adversely affect neuroplasticity. Diazepam also has potential for abuse and dependence so consideration needs to be given to the patient population before prescribing. It should usually only be for short term use where painful spasms are particularly severe, with the intention to transfer to other agents in the longer term.
A number of agents can be used to treat generalised spasticity. Prescribing and dose titration of these agents should only be done as part of MDT discussions between a doctor with expertise in spasticity management and therapists with neuro-rehabilitation expertise. Commonly used agents include:

  • Baclofen (GABA-B agonist) is the most commonly used first line drug usually commencing at 5mg tds. Dosing should be reviewed twice weekly and can be titrated gradually upwards to a maximum of 100mg daily. Rapid increases in dose should be avoided to avoid sedation and hypotonia.

Second line agents which can be used as an alternative or in addition include:

  • Tizanidine - 2 mg at night and gradually add a 2mg dose every second day until the patient is receiving 3 doses daily. The dose may then be increased gradually (to a maximum of 36 mg/day) to achieve the desired control of spasticity. This regimen may help avert dizziness, dryness of mouth and sedation. Liver function tests should be carried out before starting this drug, 4-6 weeks after and every 6 months after that.
  • Dantrolene - Liver function tests should be carried out before the start of treatment and regularly afterwards. Dantrolene has a greater propensity to cause muscle weakness.

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21. Psychological and Emotional Support

Each patient reacts uniquely to their own diagnosis of SCI. Experiencing a SCI is frightening as patients usually maintain capacity, and frequently produces extreme emotional reactions. Feelings vary from each individual but it is important for health care professionals to recognize these thoughts and feelings in order to support appropriately. Support for both patients and their families can be in the form of medical professionals on the unit or within the hospital, with a clinical psychologist, telephone support through a number of charities or an individual with a SCI themselves that has a good quality of life (allocated through SIA). A chaplain may be an option initially, even if the person is not religious as humanist chaplains are available. Chaplains work on call and can be contacted via switchboard. There are a number of online communities for example the SIA message board and chat room which may be a helpful space to share experiences.15

Many patients with high SCI have a tracheostomy so initially may not be able to express their wishes for cares. It is important to establish a care plan based on the patient’s wishes at the earliest opportunity. This can include likes, dislikes, hobbies or distractions, therapy times etc. A ‘get to know me’ board can be filled out with family initially to help staff know more about the patient in order to help aid patient centered care.16

Back up Back up are a charity that can provide a mentoring support service for patients with SCI and family members on 020 8875 1805 or e-mail outreachandsupport@backuptrust.org.uk

The British Pain society Run pain management programmes aimed at improving the quality of life of those with chronic pain. The pain management programme teaches the patients relaxation techniques and how to understand the psychological effects of persistent pain.17 Referral can be made through GP or pain specialist.

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22. Pharmacological Treatment for Reactive depression/Low mood

Patients should be reviewed every 1–2 weeks at the start of antidepressant treatment. Treatment should be continued for at least 4 weeks (6 weeks in the elderly) before considering whether to switch antidepressant due to lack of efficacy. In cases of partial response, continue for a further 2–4 weeks (elderly patients may take longer to respond).

Following remission, antidepressant treatment should be continued at the same dose for at least 6 months (about 12 months in the elderly), or for at least 12 months in patients receiving treatment for generalised anxiety disorder (as the likelihood of relapse is high). Patients with a history of recurrent depression should receive maintenance treatment for at least 2 years.

Selective serotonin re-uptake inhibitors (SSRIs) are better tolerated and are safer in overdose than other classes of antidepressants and should be considered first-line for treating depression. In patients with unstable angina or who have had a recent myocardial infarction, sertraline has been shown to be safe.

Tricyclic antidepressants have similar efficacy to SSRIs but are more likely to be discontinued because of side-effects; toxicity in over dosage is also a problem. SSRIs are less sedating and have fewer antimuscarinic and cardiotoxic effects than tricyclic antidepressants.

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23. Night Sedation / Delirium

Where a patient is experiencing low mood or has associated problems with neuropathic pain, Amitriptyline is the most appropriate agent to use for night sedation. However if muscle spasm is a clinical feature then Temazepam is a more suitable agent for night sedation. Be aware that benzodiazepines can caused REM rebound AND withdrawal symptoms such as hypertension, tachycardia and apnoea. Seek advice from medical team/pharmacist if alternatives are required.

Please consider assessment tools to assess for delirium and the use of medication if required. For further information please use the Assessment and Treatment of Agitation/Delirium within Adult Critical Care:
http://www.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=5570

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24. Financial Support

Day One Charity The charity provides practical and emotional support for patients and family members in the immediate aftermath of a major trauma and throughout the recovery journey. Contact at dayone@leeds-cares.org or 07375113044.

Aspire www.aspire.org.uk A charity that provides practical help to people who have a SCI. This includes: Independent living advisors who can offer assistance when applying for carers’ allowance (apply for carers allowance at www.gov.uk or welfare benefit advice 020 8420 6711).

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Appendix 1:

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Appendix 2

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Appendix 3

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Appendix 4

Provenance

Record: 4782
Objective:

These guidelines have been produced and updated to support teams in the management of patients with cervical cord injury in the acute phase and the respiratory wean of these complex patients by using supporting evidence on best practice.

 

Primary injury is the damage caused to the spinal cord at the time of injury. Primary injuries may be traumatic or non-traumatic in nature; the damage caused at this point is non-reversible. Secondary injuries occur during the following hours to days and involve vascular compromise, inflammatory changes and cellular dysfunction. A key aim of management is stabilisation and prevention of further injury.

Clinical condition:

Spinal Injury (Adults)

Target patient group: Patients in level 2 and 3 of Critical Care with a diagnosis of Spinal Cord Injury
Target professional group(s): Allied Health Professionals
Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

References

  1. Acute management of traumatic cervical spinal injury. (2015)  Ropper A.E, Neal M.T. Theodore, N. Practical Neurology.; vol 10; 1136
  2. The acute respiratory management of cervical spinal cord injury in the first 6 weeks after injury. A systematic review. Berney S et al. Spinal Cord 2011: 49: 17-29.
  3. Acute Spinal cord injury.  White, J and Thumbikat, P.  Orthopaedics II: Spine and Pelvis.  2012: 30.7: 326-332.
  4. Spinal Injury: Assessment and initial management.  Nice.org.uk.  2016.
  5. Care management pathway for the acute patient with and actual spinal cord injury.  SCI-link trauma and critical care network.  2013.
  6. Respiratory management following spinal cord injury. (2018) Sheel, A W, Welsh, J F, Townson, A. F.    Spinal cord injury rehabilitation evidence.  Version 6.0.  Vancover: p 1-72.
  7. Managing Spinal Cord Injury: the first 48 hours.  Harrison, P.  Spinal Injury Association.  2007.
  8. Managing Spinal Injury: Critical Care.  Harrison, P.  2000.
  9. Autonomic Dysreflexia: Living with SCI factsheet.  Spinal Injuries Association.  2013.
  10. Level 1A evidence:  7th ACCP conference on antithrombotic and thrombolytic therapy.  Chest 2004; 126:  172S
  11. TRISS Trial Group.  (2014).  Lower Versus Higher Haemoglobin Threshold For Transfusion In Septic Shock.  The New England Journal of Medicine; 371; P1381-1391.
  12. Forum of SCI centre Dieticians.  (2010).  Nutritional Management of Acute Spinal Cord Injury Patients in Critical Care Environments.
  13. NHS Improvement.  (2018).  Patient Safety Alert: Resources to Support Safer Bowel Care for Patients at Risk of Autonomic Dysreflexia.
  14. Positioning the Critically Ill Patient in Hospital.  Griffiths, H and Gallimore, D.  (2005).  Nursing Standards; Vol 19. 42. P56-64.
  15. NSCIB (2012).  The Initial management of Adults with Spinal Cord Injuries.  MASCIP.
  16. Guide for Health professionals on the Psychological Care of adults with Spinal Cord Injury. Craig, A.  (2013).
  17. The British Pain Society.  (2013).  Participant Information for Pain Management programs.  British pain Society.
  18. Respiratory problems and management in people with spinal cord injury. Berlowitz D, J, Wadsworth, B, and Ross,J. 2016. Breathe. 12, 328-340.
  19. NIPPY Clearway user manual. B+D Electromedical. Version 4. (2014) Accessed via http://nippyventilator.com/products/nippy-clearway/
  20. Study of the effectiveness of bronchial clearance in subjects with upper spinal cord injuries: examination of a rehabilitation programme involving mechanical insufflation and exsufflation. Pillastrini P, Bordini S, Bazzocchi G, Belloni G, Menarini M. Spinal Cord 2006; 44: 614–616.
  21. Mechanical insufflation-exsufflation device prescription for outpatients with tetraplegia. Crew JD, Svircev JN, Burns SP.  J Spinal Cord Med 2010; 33: 128-134
  22. Effects of air stacking on pulmonary function and peak cough flow in patients with cervical spinal cord injury. Jeong JH, Yoo WG.  Journal of Physical Therapy Science. 2015, 27: 1951–1952.
  23. The effect of intermittent positive pressure breathing on lung volumes in acute quadriparesis. Stiller K, Simionato R, Rice K, Hall B.  Paraplegia 1992; 30: 121-126.
  24. Intermittent positive-pressure breathing effects in patients with high spinal cord injury. Laffont I, Bensmail D, Lortat-Jacob S, Falaize L, Hutin C, Le Bomin E, Ruquet M, Denys P, Lofaso F. Arch Phys Med Rehabil 2008; 89: 1575-1579.
  25. Facilitating Airway Clearance with Coughing Techniques. Amsterdam, Elsevier Health Sciences, 2014. Frownfelter D, Massery M, eds.
  26. Pathophysiology of spasticity: implications for neurorehabilitation. Trompetto C, Marinelli L, Mori L, et al.  Biomed Res Int. 2014;2014:354906. doi:10.1155/2014/354906
  27. Acute management of traumatic cervical spinal cord injury. AERopper, MT Neal NTheodore. Practical Neurology 2015; 15: 266-72.
  28. Pharmacological management in OH in SCI. A Krassioukova, JM Wecht, RW Teasell, JJ Eng. Spinal cord injury rehabilitation evidence. 11-13.
  29. Acute Respiratory Management following Spinal Cord Injury. (2019) Mullen, E., Faltynek, P., Mirkowski, M., Benton, B., Mcintyre, A., Vu, V. and Teasell, R. Spinal Cord Injury Rehabilitation Evidence (SCIRE). Version 7.0: p 1-51. https://scireproject.com/wp-content/uploads/Respiratory_V7.0.pdf

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

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