2025 Southeastern Residency Conference

Title: Evaluation of Pseudoephedrine as Adjunctive Therapy in Acute Spinal Cord injuries


Authors: Gianna Antinone, Taylor Law, Amanda McKinney, Mary Massaro, John Gripentrog, Stephanie Scott, and A. Shaun Rowe


Objective: To evaluate the efficacy of pseudoephedrine as an adjunctive agent to IV vasopressors in acute spinal cord injuries 


Self Assessment Question: True/False: The addition of oral pseduoephedrine to IV vasopressors for MAP augmentation post-SCI resulted in a short duration of IV vasopressors.  Answer: False


Background: Spinal cord injury (SCI) is defined as acute traumatic damage to the spinal cord, resulting in temporary or permanent neurolgical damage. Neurogenic shock, defined as bradycardia and hypotension, is common within this population. The relative recommendation immediately after injury is to augment mean arterial pressure (MAP) to a goal of 85-90 mmHg for one week to adequately perfuse the spinal cord. Commonly used treatments for MAP augmentation include intravenous (IV) and oral vasopressors such as pseudoephedrine (PSE) and midodrine. This study evaluates the efficacy of pseudephedrine as an adjunctive agent to IV vasopressors in patients with acute spinal cord injuries. 


Methods: We performed a retrospective cohort study of trauma-surgical critical care patients at the University of Tennessee Medical Center from October 1, 2015, to January 1, 2024. Patients were included if 18 years of age and older, diagnosed with a spinal cord injury, and required IV vasopressor intiation upon admission to achieve a MAP goal > 85 mmHg for the first 5 days after injury. Patients were divided into two groups of either vasopressor monotherapy or vasopressor in combination with PSE to augment the goal MAP. The primary outcome of this study compared the time to IV vasopressor discontinuation between the two groups. Secondary outcomes included incidence of central line placement and duration, ICU and hospital length of stay, all-cause ICU and hospital mortality, successful discontinuation of IV vasopressors post-pseduoephedrine initiation, IV vasopressor re-initation within 24hrs of discontinuation, and incidence of bradycardia. 


Results: Among the 751 patients identified for inclusion, 201 patients met inclusion criteria, of which 136 patients received vasopressor monotherapy, whereas 65 patients received vasopressor plus adjunctive PSE to maintain MAP goals. The duration of IV vasopressors was 70 hours versus 106 hours in the adjunctive PSE group (p=0.0299). Central line placement, duration of central line placement, hospital and ICU length of stay, hospital mortality, and ICU mortality were similar between the two groups. 80.7% of patients has successful discontinuation of vasopressors once PSE was initated. The incidence of bradycardia was more prominent in the adjunctive PSE group (44.6%) compared to vasopressors alone (25.7%), p=0.0072. 


Conclusion: Although this study did not meet the primary outcome of reducting time to IV vasopressor discontinuation, this study demonstrated successful discontionuation of vasopressors post-PSE iniation in 80% of the study population who received PSE as adjunctive therapy. This study is limited by a small sample population and retrospective nature.