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Anesthesia for Autonomic Hyperreflexia: Case Presentation & Review Mark Todd Wright, SRNA AVANA Conference 2013 OHSU Nurse Anesthesia Program.

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Presentation on theme: "Anesthesia for Autonomic Hyperreflexia: Case Presentation & Review Mark Todd Wright, SRNA AVANA Conference 2013 OHSU Nurse Anesthesia Program."— Presentation transcript:

1 Anesthesia for Autonomic Hyperreflexia: Case Presentation & Review Mark Todd Wright, SRNA AVANA Conference 2013 OHSU Nurse Anesthesia Program

2 Disclosures $10,000 from AVANA

3 Case Presentation

4 Autonomic Hyperreflexia

5 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)

6 AH Case Presentation Active 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)

7 AH Case Presentation Medical History AH during previous anesthetic HTN-resolved

8 AH Case Presentation Labs & Diagnostics 12-lead EKG: NSR (01/2013) BMP: WNL Hgb: 11.1 Hct: 36.0 Plt: 157 INR 1.2 HR: 63BP: 123/73RR: 16SpO2: 98%T: 36.6˚C

9 AH Case Presentation Airway/ROS Auscultation: RRR CTA Airway ROM: (-) Dentition: (-) Neck: (-) T→D: (-) ULBT: grade I Mouth: > 3 cm MP: 2 Anatomy palp: easy

10 AH Case Presentation Spinal & Induction 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

11 AH Case Presentation: Maintenance, Emergence, & Postop Sevoflurane 1-1.5% BIS Fentanyl prn Nipride gtt (readily available)

12 AH Case Presentation: Maintenance, Emergence, & Postop

13 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 ↑ > mmHg

14 VA & Spinal Cord Injury (SCI) 250,000 Americans w/ serious SCI 42,000 SCI Veterans/heroes 26,000 (2008) 13,000 specialty care (2008)

15 AH Pathophysiology Review 1)Stimulus below transection. 2)Activation of preganglionic sympathetic nerves 3)Vasoconstriction 4)HTN 5)Stimulation of carotid sinus = bradycardia 6)Reflexive cutaneous vasodilation

16 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

17 Autonomic Hyperreflexia

18 AH Anesthetic Implications Pre-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

19 AH Anesthetic Implications Treatment 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)

20 AH Anesthetic Implications Clinical 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

21 References 1.Fleisher LA, Roizen MF. Essence of Anesthesia Practice. 3 rd ed. Philadelphia/Elsevier. 2011; Hines RL, Marshall KE eds. Stoelting’s Anesthesia and Co-Existing Disease. 5 th ed. Philadelphia: Churchill Livingstone/Elsevier; Lagarto, F., Pina, P.. Autonomic Dysreflexia - a clinical case: 4AP8-7. Eur J Anaesthesiol. 2012;29:75. Cited in: Your Full Text at WS=N&AN= Accessed April 02, WS=N&AN= Groothuis, Jan, Rongen, Gerard, Deinum, Jaap, et al. Sympathetic Nonadrenergic Transmission Contributes to Autonomic Dysreflexia in Spinal Cord-Injured Individuals. Hypertension. 2010;55(3): doi: /HYPERTENSIONAHA Stevens, Robert, Bhardwaj, Anish, Kirsch, Jeffrey, Mirski, Marek. Critical Care and Perioperative Management in Traumatic Spinal Cord Injury. J Neurosurg Anesthesiol. 2003;15(3): Cited in: Your Full Text at S=N&AN= Accessed April 02, S=N&AN=

22 References 5.BROECKER, B., HRANOWSKY, N., HACKLER, R.. Low Spinal Anesthesia for the Prevention of Autonomic Dysreflexia in the Spinal Cord Injury Patient. Surv. anesthesiol ;24(3):184. Cited in: Your Full Text at WS=N&AN= Accessed April 02, WS=N&AN= Spinal Cord Injury Fact Sheet for Veterans:

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