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Ann Thorac Surg 2004;78:2214
© 2004 The Society of Thoracic Surgeons
Division of Cardiovascular Surgery, Mayo Clinic, 200 First St, NW, Rochester, MN 55905, USA
sundt.thoralf{at}mayo.edu
To the Editor:
I appreciate the interest shown by Hunt and colleagues in our report [1] on delayed paraplegia. It is important that surgeons be aware of this risk, and the more the issue is discussed, the more likely the information is to be heard. Our colleagues from St. Thomas' Hospital take exception to our approach to the management of delayed paraplegia, specifically our decision not to reinsert drains late postoperatively.
To be frank, I cannot argue with them. Before addressing this issue, however, I emphasize that the most important lesson we learned, and the principal message we wished to convey, concerned prevention of the complication. Operations for thoracoabdominal aortic aneurysms can be very "wet," and as a surgeon who has spent a considerable amount of time in the operating room trying to make them "dry," it is tempting to tell the intensive care unit nurses to "keep the blood pressure under tight control," ie, low. We learned that for these patients, tight control should mean high. Having talked with surgeons and intensivists with other backgrounds and other experiences, we found it apparent that this important principle is not widely appreciated. We believe that tenets such as this to prevent paraplegia will likely have greater impact on outcomes than any measures to reverse the complication.
In regard to the management of delayed paraplegia, we did not intend to advocate our approach but merely to be honest about what our practice had been during the study interval. We wrote that "it was not our routine to reinsert a drain." Hunt and coauthors share an anecdotal case of late reversal of paraplegia and argue in favor of an aggressive approach to reinsertion of a spinal drain. They also cite the experience of others in support of their argument. As it happens, during the same session of the 2002 annual meeting of The Society of Thoracic Surgeons at which our study was presented, our colleagues at the University of Pennsylvania addressed this issue specifically in a much larger experience [2]. Like Hunt and associates, they are aggressive in reinserting such drains.
Would I reinsert a drain today for delayed paraplegia? Likely so. I find the arguments made by the groups at St. Thomas' Hospital, the University of Pennsylvania [2], and the University of Texas [3] persuasive. Most importantly, I would keep the blood pressure high.
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