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KSR Number: KSRA71142

The impact of blood pressure management after spinal cord injury: a systematic review of the literature

Risk of Bias Assessment

Overall summary: High risk of bias in the review

Bottom Line

Current evidence suggests that blood pressure management with vasopressors (such as dopamine, norepinephrine or phenylephrine) may stabilise or improve neurological outcomes in patients with spinal cord injury (SCI). However, more complications may be associated with the use of dopamine compared to other vasopressors. A tentative target of a mean arterial pressure of 85-90 mmHg for 5 to 7 days may be considered. However, these findings must be interpreted with caution as important methodological issues mean that relevant articles may have been missed, and error and bias may have been present.

Risk of Bias Assessment

Overall summary High risk of bias in the review


Studies not published in English were excluded and only a single database was searched, meaning relevant articles may have been missed. No information was provided on the number of authors involved in study selection or data extraction, meaning error and bias may have been present. No risk of bias assessment was performed.

A. Did the interpretation of findings address all of the concerns identified in Domains 1 to 4? No
B. Was the relevance of identified studies to the review's research question appropriately considered? No information
C. Did the reviewers avoid emphasizing results on the basis of their statistical significance? No information
Risk of bias in the review High

Details of Review

Number of studies 11
Number of participants 788
Last search date 25 July 2017
Review type Intervention
Objective To review the evidence behind blood pressure management after a spinal cord injury.
Population Patients who suffered SCIs.
Interventions Blood pressure (BP) management.
Comparator Unclear.
Outcome Neurological outcomes, improve blood pressure management, mean arterial pressure (MAP) goal, and MAP goal duration.
Study design Prospective and retrospective case series.

Animal studies were excluded.
Exposure Spinal cord injury.


Seven out of nine studies reported a goal MAP of higher than 85 mm Hg in patients who suffered SCIs and were managed after injury and the remaining two studies observed that the MAP goals were found to be higher than 85 mm Hg and higher than 90 mm Hg, respectively.

Similarly, six retrospective studies found that the duration of blood pressure management varied from more than 24 hours to 7 days. The remaining two prospective studies observed the duration of treatment of 7 days. In addition, neurological outcomes were found to be stable or improved with blood pressure management.

Studies demonstrated that interventions such as dopamine, norepinephrine, and phenylephrine were the agents that were frequently used in the management of blood pressure. However, dopamine was found to be associated with more complications when compared to the other vasopressors in patients after spinal cord injury.

Full Risk of Bias Assessment

The research question was clear. No restrictions were reported based on study characteristics. Non-English studies were excluded.

1.1 Did the review adhere to pre-defined objectives and eligibility criteria? Probably yes
1.2 Were the eligibility criteria appropriate for the review question? Probably yes
1.3 Were eligibility criteria unambiguous? Probably yes
1.4 Were all restrictions in eligibility criteria based on study characteristics appropriate (e.g. date, sample size, study quality, outcomes measured)? Probably yes
1.5 Were any restrictions in eligibility criteria based on sources of information appropriate (e.g. publication status or format, language, availability of data)? Probably no
Concerns regarding specification of study eligibility criteria High

Only one electronic database (PubMed) was searched which is not sufficient for a systematic review. Identified articles were reference checked but there were no further attempts to find unpublished or grey literature. Search terms were provided, but a full search strategy was not reported so it is not possible to judge whether it was adequate. However, it was reported that no date restrictions were applied. No information was provided on whether there were restrictions on publication format or language and it was also not reported whether studies were independently screened or not.

2.1 Did the search include an appropriate range of databases/electronic sources for published and unpublished reports? No
2.2 Were methods additional to database searching used to identify relevant reports? Probably yes
2.3 Were the terms and structure of the search strategy likely to retrieve as many eligible studies as possible? Probably no
2.4 Were restrictions based on date, publication format, or language appropriate? No information
2.5 Were efforts made to minimise error in selection of studies? No information
Concerns regarding methods used to identify and/or select studies High

Information regarding the number of authors involved in the data extraction was not provided. There were no formal assessments of the methodological quality of included studies. The review does not provide critical details on the included studies such as the actual blood pressure target figure, the relative time between the provision of the intervention and the injury, a comprehensive description of the vasopressor employed including dosage or the actual individual results.

3.1 Were efforts made to minimise error in data collection? No information
3.2 Were sufficient study characteristics considered for both review authors and readers to be able to interpret the results? No
3.3 Were all relevant study results collected for use in the synthesis? Probably yes
3.4 Was risk of bias (or methodological quality) formally assessed using appropriate criteria? No
3.5 Were efforts made to minimise error in risk of bias assessment? No
Concerns regarding methods used to collect data and appraise studies High

The synthesis included all relevant studies and was appropriate. A narrative synthesis was performed to summarise the findings. The quality of individual studies was not considered in the synthesis of findings. No analysis was performed, so there was no information on robustness of the findings.

4.1 Did the synthesis include all studies that it should? Yes
4.2 Were all pre-defined analyses reported or departures explained? Yes
4.3 Was the synthesis appropriate given the degree of similarity in the research questions, study designs and outcomes across included studies? Yes
4.4 Was between-study variation minimal or addressed in the synthesis? Probably yes
4.5 Were the findings robust, e.g. as demonstrated through funnel plot or sensitivity analyses? No information
4.6 Were biases in primary studies minimal or addressed in the synthesis? No
Concerns regarding synthesis and findings High