Difference between revisions of "Autonomic dysreflexia"
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}}'''Autonomic dysreflexia''' is potentially life threatening sympathetic hyperactivity which can emerge | }}'''Autonomic dysreflexia''' is potentially life threatening sympathetic hyperactivity in patients with spinal cord injury which can emerge in response to noxious or non-noxious stimulation below the level of injury. Autonomic dysreflexia typically occurs in patients with lesions at or above T6, but has been reported in injuries as low as T10.<ref>{{Cite journal|last=Vallès|first=M.|last2=Benito|first2=J.|last3=Portell|first3=E.|last4=Vidal|first4=J.|date=2005|title=Cerebral hemorrhage due to autonomic dysreflexia in a spinal cord injury patient|url=https://pubmed.ncbi.nlm.nih.gov/16010281|journal=Spinal Cord|volume=43|issue=12|pages=738–740|doi=10.1038/sj.sc.3101780|issn=1362-4393|pmid=16010281|via=}}</ref> | ||
==Anesthetic implications<!-- Briefly summarize the anesthetic implications of this comorbidity. -->== | ==Anesthetic implications<!-- Briefly summarize the anesthetic implications of this comorbidity. -->== | ||
===Preoperative optimization<!-- Describe how this comorbidity may influence preoperative evaluation and optimization of patients. -->=== | ===Preoperative optimization<!-- Describe how this comorbidity may influence preoperative evaluation and optimization of patients. --> === | ||
Preoperative history is essential in alerting the anesthesiologist to the possibility of intraoperative AD. Key information includes the spinal cord injury history (timing, degree of injury and importantly the level), prior history of autonomic dysreflexia and associated triggers (if known). | Preoperative history is essential in alerting the anesthesiologist to the possibility of intraoperative AD. Key information includes the spinal cord injury history (timing, degree of injury and importantly the level), prior history of autonomic dysreflexia and associated triggers (if known). | ||
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For patients with no sensation at the surgical site and with injury below T6, MAC is an acceptable option. <ref>{{Cite web|last=Mathews|first=Letha|date=May 2021|title=Anesthesia for adults with chronic spinal cord injury|url=https://www.uptodate.com/contents/anesthesia-for-adults-with-chronic-spinal-cord-injury|url-status=live|archive-url=|archive-date=|access-date=2021-06-18|website=www.uptodate.com}}</ref> | For patients with no sensation at the surgical site and with injury below T6, MAC is an acceptable option. <ref>{{Cite web|last=Mathews|first=Letha|date=May 2021|title=Anesthesia for adults with chronic spinal cord injury|url=https://www.uptodate.com/contents/anesthesia-for-adults-with-chronic-spinal-cord-injury|url-status=live|archive-url=|archive-date=|access-date=2021-06-18|website=www.uptodate.com}}</ref> | ||
===Postoperative management<!-- Describe how this comorbidity may influence postoperative management. --> === | ===Postoperative management<!-- Describe how this comorbidity may influence postoperative management. -->=== | ||
==Related surgical procedures<!-- List and briefly describe any procedures which may be performed specifically to treat this comorbidity or its sequelae. If none, this section may be removed. --> == | ==Related surgical procedures<!-- List and briefly describe any procedures which may be performed specifically to treat this comorbidity or its sequelae. If none, this section may be removed. -->== | ||
==Pathophysiology<!-- Describe the pathophysiology of this comorbidity. Add subsections as needed. -->== | ==Pathophysiology<!-- Describe the pathophysiology of this comorbidity. Add subsections as needed. -->== | ||
==Signs and symptoms<!-- Describe the signs and symptoms of this comorbidity. -->== | == Signs and symptoms<!-- Describe the signs and symptoms of this comorbidity. -->== | ||
Sympathetic hyperreactivity below the lesion presents with vasoconstriction (pale, dry skin), systemic hypertension and associated headache. Parasympathetic hyperreactivity above the lesion presents with vasodilation, flushing, piloerection, miosis, nausea, and vomiting. Awake patients may also endorse lightheadedness, anxiety, and sensation of doom. | Sympathetic hyperreactivity below the lesion presents with vasoconstriction (pale, dry skin), systemic hypertension and associated headache. Parasympathetic hyperreactivity above the lesion presents with vasodilation, flushing, piloerection, miosis, nausea, and vomiting. Awake patients may also endorse lightheadedness, anxiety, and sensation of doom. | ||
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==Treatment<!-- Summarize the treatment of this comorbidity. Add subsections as needed. -->== | ==Treatment<!-- Summarize the treatment of this comorbidity. Add subsections as needed. -->== | ||
===Medication<!-- Describe medications used to manage this comorbidity. -->=== | ===Medication<!-- Describe medications used to manage this comorbidity. --> === | ||
===Surgery<!-- Describe surgical procedures used to treat this comorbidity. -->=== | === Surgery<!-- Describe surgical procedures used to treat this comorbidity. -->=== | ||
===Prognosis<!-- Describe the prognosis of this comorbidity -->=== | ===Prognosis<!-- Describe the prognosis of this comorbidity -->=== | ||
Revision as of 02:27, 19 June 2021
| Other names | Mass reflex |
|---|---|
| Anesthetic relevance |
Critical |
| Anesthetic management |
Consider neuraxial or MAC |
| Specialty |
Neurology, Cardiology |
| Signs and symptoms |
Hypertension |
| Diagnosis |
Most common with lesions above T6. Has been described in lesions as low as T10 |
| Treatment |
Rapidly titratable vasodilators Deepen anesthesia |
| Article quality | |
| Editor rating | |
| User likes | 0 |
Autonomic dysreflexia is potentially life threatening sympathetic hyperactivity in patients with spinal cord injury which can emerge in response to noxious or non-noxious stimulation below the level of injury. Autonomic dysreflexia typically occurs in patients with lesions at or above T6, but has been reported in injuries as low as T10.[1]
Anesthetic implications
Preoperative optimization
Preoperative history is essential in alerting the anesthesiologist to the possibility of intraoperative AD. Key information includes the spinal cord injury history (timing, degree of injury and importantly the level), prior history of autonomic dysreflexia and associated triggers (if known).
The planned procedure also significantly impacts the likelihood of intraoperative AD. Stimulus above the injury level are less likely to provoke autonomic dysreflexia while injuries below are higher risk.
Intraoperative management
An anesthetic plan can include general or neuraxial techniques for patients at risk.
If general anesthesia is chosen, patients should be kept at a sufficiently deep level of anesthesia to prevent dysreflexia. Fast acting agents that can quickly be titrated are preferred such as Propofol and the insoluble volatile anesthetics.
Neuraxial anesthesia may be used, especially a spinal which can effectively prevent the development of autonomic dysfunction. However, limitations include difficulty determining the level of spinal block. Epidural anesthesia is less effective than spinal anesthesia for patients with SCI but can be considered.
For patients with no sensation at the surgical site and with injury below T6, MAC is an acceptable option. [2]
Postoperative management
Related surgical procedures
Pathophysiology
Signs and symptoms
Sympathetic hyperreactivity below the lesion presents with vasoconstriction (pale, dry skin), systemic hypertension and associated headache. Parasympathetic hyperreactivity above the lesion presents with vasodilation, flushing, piloerection, miosis, nausea, and vomiting. Awake patients may also endorse lightheadedness, anxiety, and sensation of doom.
Vital sign changes consistent with AD include severe hypertension and bradycardia. Hypertension can evolve to end organ dysfunction including pulmonary edema, left ventricular dysfunction, intracranial hemorrhage, seizures or even death. Bradycardia may also range from asymptomatic to sinus arrest.
Diagnosis
Treatment
Medication
Surgery
Prognosis
Epidemiology
References
- ↑ Vallès, M.; Benito, J.; Portell, E.; Vidal, J. (2005). "Cerebral hemorrhage due to autonomic dysreflexia in a spinal cord injury patient". Spinal Cord. 43 (12): 738–740. doi:10.1038/sj.sc.3101780. ISSN 1362-4393. PMID 16010281.
- ↑ Mathews, Letha (May 2021). "Anesthesia for adults with chronic spinal cord injury". www.uptodate.com. Retrieved 2021-06-18.