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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. $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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  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 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)

  7. AH Case PresentationMedical History • AH during previous anesthetic • HTN-resolved

  8. AH Case PresentationLabs & Diagnostics 12-lead EKG: NSR (01/2013) BMP: WNL Hgb: 11.1 Hct: 36.0 Plt: 157 INR 1.2

  9. AH Case PresentationAirway/ROS Auscultation: RRR CTA

  10. 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

  11. AH Case Presentation:Maintenance, Emergence, & Postop • Sevoflurane 1-1.5% • BIS 40-50 • Fentanyl prn • Nipridegtt (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 ↑ > 20-30 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 • Stimulus below transection. • Activation of preganglionic sympathetic nerves • Vasoconstriction • HTN • Stimulation of carotid sinus = bradycardia • 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 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

  19. 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)

  20. 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

  21. 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 Journals@Ovid 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 Journals@Ovid 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.

  22. 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 Journals@Ovid 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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