Downloaded from http://journals.lww.com/jtrauma by BhDMf5ePHKbH4TTImqenVL56SvJs3yjmdj5i/LCupUiyhKriqhihCd1pg61dCVTx on 11/19/2018 Use of diaphragm pacing in the management of acute cervical spinal cord injury Andrew J. Kerwin, MD, Brian K. Yorkgitis, DO, David J. Ebler, MD, Firas G. Madbak, MD, Albert T. Hsu, MD, and Marie L. Crandall, MD, MPH, Jacksonville, Florida BACKGROUND: Cervical spinal cord injury (CSCI) is devastating. Respiratory failure, ventilator-associated pneumonia (VAP), sepsis, and death frequently occur. Case reports of diaphragm pacing system (DPS) have suggested earlier liberation from mechanical ventilation in acute CSCI patients. We hypothesized DPS implantation would decrease VAP and facilitate liberation from ventilation. METHODS: We performed a retrospective review of patients with acute CSCI managed at a single Level 1 trauma center between January 2005 and May 2017. Routine demographics were collected. Patients underwent propensity matching based on age, injury severity score, ventilator days, hospital length of stay, and need for tracheostomy. Outcome measures included hospital length of stay, intensive care unit length of stay, ventilator days (vent days), incidence of VAP, and mortality. Bivariate and multivariate logistic and linear regression statistics were performed using STATAVersion 10. RESULTS: Between July 2011 and May 2017, all patients with acute CSCI were evaluated for DPS implantation. Forty patients who had lap- aroscopic DPS implantation (DPS) were matched to 61 who did not (NO DPS). Median time to liberation after DPS implantation was 7 days. Hospital length of stay and mortality were significantly lower on bivariate analysis in DPS patients. Diaphragm pacing system placement was not found to be associated with statistically significant differences in these outcomes on risk-adjusted mul- tivariate models that included admission year. CONCLUSIONS: Diaphragm pacing system implantation in patients with acute CSCI can be one part of a comprehensive critical care program to improve outcomes. However, the association of DPS with the marked improved mortality seen on bivariate analysis may be due solely to improvements in critical care throughout the study period. Further studies to define the benefits of DPS implantation are needed. (J Trauma Acute Care Surg. 2018;85: 928–931. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.) LEVEL OF EVIDENCE: Therapeutic, level IV. KEY WORDS: Cervical spinal cord injury; diaphragm pacing; ventilator weaning; tetraplegia. I t is estimated that there are 17,000 new spinal cord injuries (SCIs) each year in the United States. 1 Injury to the spinal cord, particularly the cervical spine and upper thoracic spine, often leads to respiratory dysfunction, including inadequacy of respiratory muscles, reduction in vital capacity, ineffective cough and secretion clearance, and reduced compliance of lung and chest wall. 2 Respiratory complications are the most com- mon etiology of morbidity and mortality. 3–5 More half of complete cervical SCI (CSCI) patients re- quire mechanical ventilation upon hospital discharge. 6 The need for long-term ventilation is estimated at 40% to 85% among high SCI patients with the need increasing for higher level of injury. 7,8 This presents a significant challenge for dis- charge to a rehabilitation center and reintegration back into the community, as they require prolonged intensive care needs. These individuals also are particularly prone to repeated respiratory infections. 4 Additionally, the quality of life reported by ventilated SCI patients is lower than their nonventilated counterparts. 9 Various methods have been used to assist in liberating CSCI patients from mechanical ventilation. 10–13 Among these modalities, the use of diaphragm pacing has shown promis- ing results. Diaphragm pacing system (DPS) implantation is achieved (traditionally via the laparoscopic technique) of elec- trodes into the diaphragm muscles that are then connected to an external pulse generator. Through the impulses created by the external pulse generator, the diaphragm is stimulated and contraction occurs. 14 Posluszny et al. 15 in a multicenter trial of 29 patients demonstrated the effectiveness of early DPS implan- tation in acute CSCI through liberation from the ventilator in 16 of 22 (72%) CSCI patients. Patients who underwent DPS place- ment were liberated from mechanical ventilation in an average of 10.2 days after DPS implantation. Acute CSCI patients requiring mechanical ventilation are candidates for DPS to assist with ventilator liberation. To allevi- ate muscle and nerve atrophy from loss of neurostimulation in CSCI patients, earlier DPS implantation may mitigate this dysfunction and result in increased ability for diaphragm stimu- lation. We hypothesized that early DPS implantation (as soon as possible after correction of physiologic derangement during the initial hospitalization) for acute CSCI patients would decrease ventilator-associated pneumonia (VAP) and facilitate liberation from ventilation. Submitted: February 12, 2018, Revised: May 20, 2018, Accepted: June 23, 2018, Pub- lished online: July 6, 2018. From the University of Florida College of Medicine-Jacksonville, Jacksonville, Florida. Address for reprints: Andrew J Kerwin, MD, Division of Acute Care Surgery, University of Florida College of Medicine- Jacksonville, 655 W 8th St, Jacksonville, FL 32209; email: andy.kerwin@jax.ufl.edu. This study was presented at the 48th Annual Meeting of the Western Trauma Association, March 2, 2018, Whistler, British Columbia. The authors declare no conflicts of interest. The authors declare no disclosures on funding. DOI: 10.1097/TA.0000000000002023 2018 WTA PODIUM PAPER 928 J Trauma Acute Care Surg Volume 85, Number 5 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.