Anesthesia for autonomic hyperreflexia case presentation review
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Anesthesia for Autonomic Hyperreflexia: Case Presentation & Review. Mark Todd Wright, SRNA AVANA Conference 2013 OHSU Nurse Anesthesia Program. Disclosures. $10,000 from AVANA. Case Presentation. Autonomic Hyperreflexia. AH Case Presentation.

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Anesthesia for Autonomic Hyperreflexia: Case Presentation & Review

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Anesthesia for autonomic hyperreflexia case presentation review

Anesthesia for Autonomic Hyperreflexia: Case Presentation & Review

Mark Todd Wright, SRNA

AVANA Conference 2013

OHSU Nurse Anesthesia Program


Disclosures

Disclosures

  • $10,000 from AVANA


Case presentation

Case Presentation


Autonomic hyperreflexia

Autonomic Hyperreflexia


Ah case presentation

AH Case Presentation

  • 63 y/o M, scheduled for a sigmoid colectomy w/ colostomy.

  • NKA

  • BMI 29.3 / 98 Kg

  • Tobacco: 20 pk/yr (quit 2007)


Ah case presentation active problems

AH Case PresentationActive Problems

  • Quadriplegia—C5-C7 transection

    • X6 yrs

  • Chronic pain

    • Oxycodone 5 mg 1-2 tabs q 4 hrs

    • Venlafaxine 75 mg daily

  • Mild RAD—Duoneb prn (rare use)


Ah case presentation medical history

AH Case PresentationMedical History

  • AH during previous anesthetic

  • HTN-resolved


Ah case presentation labs diagnostics

AH Case PresentationLabs & Diagnostics

12-lead EKG: NSR (01/2013)

BMP: WNL

Hgb: 11.1

Hct: 36.0

Plt: 157

INR 1.2


Ah case presentation airway ros

AH Case PresentationAirway/ROS

Auscultation:

RRR

CTA


Ah case presentation spinal induction

AH Case PresentationSpinal & Induction

  • SAB @ L3-L4 (+CSF)

    • Midazolam 1 mg IV

    • Bupi 12 mg + Epi wash

    • 500 mL LR co-load

  • Induction

    • Lidocaine 60 mg

    • Fentanyl 100 mcg

    • Propofol 120 mg

    • Rocuronium 50 mg


Ah case presentation maintenance emergence postop

AH Case Presentation:Maintenance, Emergence, & Postop

  • Sevoflurane 1-1.5%

    • BIS 40-50

  • Fentanyl prn

  • Nipridegtt (readily available)


Ah case presentation maintenance emergence postop1

AH Case Presentation:Maintenance, Emergence, & Postop


Autonomic hyperreflexia dysreflexia

Autonomic Hyperreflexia/Dysreflexia

  • Episodic & potentially life-threatening HTN that develops in pts w/ spinal cord lesion at or above T6.

    • Occurs > 85%

    • Caused by noxious, visceral, or nociceptive stimuli below spinal lesion

    • SBP ↑ > 20-30 mmHg


Va spinal cord injury sci

VA & Spinal Cord Injury (SCI)

250,000 Americans w/ serious SCI

  • 42,000 SCI Veterans/heroes

    • 26,000 (2008)

    • 13,000 specialty care (2008)


Ah pathophysiology review

AH Pathophysiology Review

  • Stimulus below transection.

  • Activation of preganglionic sympathetic nerves

  • Vasoconstriction

  • HTN

  • Stimulation of carotid sinus = bradycardia

  • Reflexive cutaneous vasodilation


Ah clinical presentation

AH Clinical Presentation

Awake:

  • C/o HA, blurred vision, nasal stuffiness

    Anesthetized:

  • Hallmarks: HTN & Bradycardia

  • Piloerection & flushing (above)

    Untreated:

  • Loss of consciousness

  • Seizures

  • Cardiac dysrhythmias

  • Cerebral, retinal, or subarachnoid hemorrhage

  • ↑ afterload → LV failure & pulm edema


Autonomic hyperreflexia1

Autonomic Hyperreflexia


Ah anesthetic implications pre op

AH Anesthetic ImplicationsPre-op

  • HEENT—↓ ROM & mouthing opening

  • CV—↓ BP, orthostatic hypoTN

  • Pulm—↓ lung volumes, cough reflex, atelectasis

  • GI—atonicity, full stomach?

  • Renal—UTI, chronic FC

  • CNS—bowel & bladder dysfunction, chronic & central pain


Ah anesthetic implications treatment

AH Anesthetic ImplicationsTreatment

  • Nifedipine or prazosin prophylaxis

  • STOP the stimulus (if possible)

  • Neuraxial block & GA

    • SAB > EA &/or GA > N2O + opioid

  • Vasodilators

    • SNP, Nicardipine

  • BB for tachyarrhythmias

  • NOTE: centrally acting hypotensive agents are not effective (clonidine)


Ah anesthetic implications clinical pearls

AH Anesthetic ImplicationsClinical Pearls

  • NDNMB prn

    • SCh & profound hyperK+

  • Common triggers:

    • Irritation of urinary bladder, colon, & labor

    • Waning of anesthesia (post-op)

  • Literature is lacking for definitive treatment


References

References

  • Fleisher LA, Roizen MF. Essence of Anesthesia Practice. 3rd ed. Philadelphia/Elsevier. 2011; 10.

  • Hines RL, Marshall KE eds. Stoelting’s Anesthesia and Co-Existing Disease. 5th ed. Philadelphia: Churchill Livingstone/Elsevier; 2008.

  • Lagarto, F., Pina, P.. Autonomic Dysreflexia - a clinical case: 4AP8-7. Eur J Anaesthesiol. 2012;29:75. Cited in: Your [email protected] Full Text at http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=yrovftm&NEWS=N&AN=00003643-201206001-00243. Accessed April 02, 2013.

  • Groothuis, Jan, Rongen, Gerard, Deinum, Jaap, et al. Sympathetic Nonadrenergic Transmission Contributes to Autonomic Dysreflexia in Spinal Cord-Injured Individuals. Hypertension. 2010;55(3):636-643. doi:10.1161/HYPERTENSIONAHA.109.147330

  • Stevens, Robert, Bhardwaj, Anish, Kirsch, Jeffrey, Mirski, Marek. Critical Care and Perioperative Management in Traumatic Spinal Cord Injury. J NeurosurgAnesthesiol. 2003;15(3):215-229. Cited in: Your [email protected] Full Text at http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=yrovftf&NEWS=N&AN=00008506-200307000-00009. Accessed April 02, 2013.


References1

References

  • BROECKER, B., HRANOWSKY, N., HACKLER, R.. Low Spinal Anesthesia for the Prevention of Autonomic Dysreflexia in the Spinal Cord Injury Patient. Surv. anesthesiol.. 1980;24(3):184. Cited in: Your [email protected] Full Text at http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=yrovfta&NEWS=N&AN=00132586-198006000-00050. Accessed April 02, 2013.

  • Spinal Cord Injury Fact Sheet for Veterans: http://www1.va.gov/opa/publications/factsheets/fs_spinal_cord_injury.pdf


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