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
• 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
• 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 during previous anesthetic
• HTN-resolved
AH Case Presentation
Labs & Diagnostics
HR: 63
BP: 123/73
RR: 16
SpO2: 98%
12-lead EKG: NSR (01/2013)
BMP: WNL
Hgb: 11.1
Hct: 36.0
Plt: 157
INR 1.2
T: 36.6˚C
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
AH Case Presentation
Spinal & 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
• Sevoflurane 1-1.5%
• BIS 40-50
• Fentanyl prn
• Nipride gtt (readily available)
AH Case Presentation:
Maintenance, Emergence, & Postop
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)
250,000 Americans w/ serious SCI
• 42,000 SCI Veterans/heroes
• 26,000 (2008)
• 13,000 specialty care (2008)
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
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 Hyperreflexia
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
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)
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
References
1.
2.
3.
4.
5.
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 Journals@Ovid Full Text at
http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=yrovftm&NE
WS=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
Neurosurg Anesthesiol. 2003;15(3):215-229. Cited in: Your Journals@Ovid
Full Text at
http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=yrovftf&NEW
S=N&AN=00008506-200307000-00009. Accessed April 02, 2013.
References
5.
6.
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 Journals@Ovid Full Text
at
http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=yrovfta&NE
WS=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