Autonomic dysreflexia - Revision history

Alex.Goodell: Added image for SCI complications

2023-09-01T18:27:24Z

Added image for SCI complications

← Older revision		Revision as of 11:27, 1 September 2023
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	\| caption =		\| caption =
	}}'''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>		}}'''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>

			==Pathophysiology<!-- Describe the pathophysiology of this comorbidity. Add subsections as needed. -->==
			[[File:Sci complications by level.jpg\|thumb]]
			Impairment of autonomic regulation due to high spinal cord injury leads to sympathetic over-reactivity. Likely, there are synaptic changes post spinal cord injury (e.g. reduced gliosis) which may contribute to impaired regulation. The result is an uninhibited sympathetic response to stimuli causing hypertension due to splanchnic and peripheral vasoconstriction. Uninjured spinal cord above the level of injury counters with a parasympathetic response which is unable to adequately regulate blood pressure but does result in a response in heart rate (i.e. bradycardia).

			Injuries below the level of T6 generally do not result in autonomic dysreflexia due to intact innervation/regulation of the splanchnic circulation.

	==Anesthetic implications<!-- Briefly summarize the anesthetic implications of this comorbidity. -->==		==Anesthetic implications<!-- Briefly summarize the anesthetic implications of this comorbidity. -->==
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	==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. -->==
	Most common surgical stimulus includes distention of hollow viscus, most commonly urinary bladder distention.		Most common surgical stimulus includes distention of hollow viscus, most commonly urinary bladder distention.

	~~==Pathophysiology<!-- Describe the pathophysiology of this comorbidity. Add subsections as needed. -->==~~
	Impairment of autonomic regulation due to high spinal cord injury leads to sympathetic over-reactivity. Likely, there are synaptic changes post spinal cord injury (e.g. reduced gliosis) which may contribute to impaired regulation. The result is an uninhibited sympathetic response to stimuli causing hypertension due to splanchnic and peripheral vasoconstriction. Uninjured spinal cord above the level of injury counters with a parasympathetic response which is unable to adequately regulate blood pressure but does result in a response in heart rate (i.e. bradycardia).

	~~Injuries below the level of T6 generally do not result in autonomic dysreflexia due to intact innervation/regulation of the splanchnic circulation.~~

	== Signs and symptoms<!-- Describe the signs and symptoms of this comorbidity. -->==		== Signs and symptoms<!-- Describe the signs and symptoms of this comorbidity. -->==

Bsumida1: Added 2 references, pathophys section

2022-07-05T01:57:52Z

Added 2 references, pathophys section

← Older revision		Revision as of 18:57, 4 July 2022
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	==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. -->==
	Most common surgical stimulus includes distention of hollow viscus, most commonly urinary bladder ~~distnetion~~		Most common surgical stimulus includes distention of hollow viscus, most commonly urinary bladder distention.

	==Pathophysiology<!-- Describe the pathophysiology of this comorbidity. Add subsections as needed. -->==		==Pathophysiology<!-- Describe the pathophysiology of this comorbidity. Add subsections as needed. -->==
			Impairment of autonomic regulation due to high spinal cord injury leads to sympathetic over-reactivity. Likely, there are synaptic changes post spinal cord injury (e.g. reduced gliosis) which may contribute to impaired regulation. The result is an uninhibited sympathetic response to stimuli causing hypertension due to splanchnic and peripheral vasoconstriction. Uninjured spinal cord above the level of injury counters with a parasympathetic response which is unable to adequately regulate blood pressure but does result in a response in heart rate (i.e. bradycardia).

			Injuries below the level of T6 generally do not result in autonomic dysreflexia due to intact innervation/regulation of the splanchnic circulation.

	== Signs and symptoms<!-- Describe the signs and symptoms of this comorbidity. -->==		== Signs and symptoms<!-- Describe the signs and symptoms of this comorbidity. -->==
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	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.		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<!~~-~~- Describe how this comorbidity is diagnosed~~. -->==		Of note, it is important to note patient's baseline resting blood pressure which may be lower in the setting of spinal cord injury (to assess for relative hypertension). This is important in early identification of AD<ref>{{Cite journal\|last=Bycroft\|first=J.\|last2=Shergill\|first2=I. S.\|last3=Chung\|first3=E. a. L.\|last4=Choong\|first4=E. a. L.\|last5=Arya\|first5=N.\|last6=Shah\|first6=P. J. R.\|date=2005-04\|title=Autonomic dysreflexia: a medical emergency\|url=https://pubmed.ncbi.nlm.nih.gov/15811886/\|journal=Postgraduate Medical Journal\|volume=81\|issue=954\|pages=232–235\|doi=10.1136/pgmj.2004.024463\|issn=0032-5473\|pmc=1743257\|pmid=15811886}}</ref>.

	==Treatment<!-- Summarize the treatment of this comorbidity. Add subsections as needed. -->==		==Treatment<!-- Summarize the treatment of this comorbidity. Add subsections as needed. -->==
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	=== Surgery<!-- Describe surgical procedures used to treat this comorbidity. -->===		=== Surgery<!-- Describe surgical procedures used to treat this comorbidity. -->===
	Stop causative stimulus – Communication with surgical team to pause surgery with the goal of limiting continued noxious stimulus while hemodynamics are addressed		Stop causative stimulus – Communication with surgical team to pause surgery with the goal of limiting continued noxious stimulus while hemodynamics are addressed

	~~===Prognosis<!-- Describe the prognosis of this comorbidity -->===~~

	==Epidemiology<!-- Describe the epidemiology of this comorbidity -->==		==Epidemiology<!-- Describe the epidemiology of this comorbidity -->==
			AD usually develops within the first year after spinal cord injury. It has been reported in anywhere between 20-70% of patients with injury above the level of T6<ref>{{Cite journal\|last=Helkowski\|first=Wendy M.\|last2=Ditunno\|first2=John F.\|last3=Boninger\|first3=Michael\|date=2003\|title=Autonomic dysreflexia: incidence in persons with neurologically complete and incomplete tetraplegia\|url=https://pubmed.ncbi.nlm.nih.gov/14997966/\|journal=The Journal of Spinal Cord Medicine\|volume=26\|issue=3\|pages=244–247\|doi=10.1080/10790268.2003.11753691\|issn=1079-0268\|pmid=14997966}}</ref>.

	==References==		==References==

Chris.Rishel: Added category

2021-06-21T02:02:56Z

Added category

← Older revision		Revision as of 19:02, 20 June 2021
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	<references />		<references />
			[[Category:Neurologic disorders]]

Mitchel.DeVita: treatment

2021-06-20T23:00:24Z

treatment

← Older revision		Revision as of 16:00, 20 June 2021
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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>

			Goal is to maintain mean arterial pressure within 20 to 25 percent of patient's baseline.

	===Postoperative management<!-- Describe how this comorbidity may influence postoperative management. -->===		===Postoperative management<!-- Describe how this comorbidity may influence postoperative management. -->===
			Minimize potential triggers of AD such as post op bladder distention

	==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. -->==
			Most common surgical stimulus includes distention of hollow viscus, most commonly urinary bladder distnetion

	==Pathophysiology<!-- Describe the pathophysiology of this comorbidity. Add subsections as needed. -->==		==Pathophysiology<!-- Describe the pathophysiology of this comorbidity. Add subsections as needed. -->==
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	===Medication<!-- Describe medications used to manage this comorbidity. --> ===		===Medication<!-- Describe medications used to manage this comorbidity. --> ===
			Management of hypertension

			* Deepen level of anesthesia, consider Mac-BAR
			* If epidural, re-dose
			* Fast-acting titratable agents:
			** Nitroprusside infusion (0.2 to 10 mcg/kg/minute)or nitroglycerin infusion (5 mcg/minute to 200 to 500 mcg/minute)
			** Nicardipine 0.2 to 0.5 mg IV bolus with nicardipine infusion (2.5 to 15 mg/hour)
			** Consider labetalol, however bradycardia usually contraindicates beta blockade

			====== Management of bradycardia: ======

			* Atropine or glycopyrrolate

	=== Surgery<!-- Describe surgical procedures used to treat this comorbidity. -->===		=== Surgery<!-- Describe surgical procedures used to treat this comorbidity. -->===
			Stop causative stimulus – Communication with surgical team to pause surgery with the goal of limiting continued noxious stimulus while hemodynamics are addressed

	===Prognosis<!-- Describe the prognosis of this comorbidity -->===		===Prognosis<!-- Describe the prognosis of this comorbidity -->===

Chris.Rishel at 10:27, 19 June 2021

2021-06-19T10:27:36Z

Chris.Rishel at 10:21, 19 June 2021

2021-06-19T10:21:08Z

← Older revision		Revision as of 03:21, 19 June 2021
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	'''Autonomic dysreflexia''' is potentially life threatening sympathetic hyperactivity which can emerge following spinal cord injury, and involves dysregulation of the autonomic nervous system leading to a disorganized response to noxious stimulus below the level of the spinal cord injury.

	{{Infobox comorbidity		{{Infobox comorbidity
	\| other_names = Mass reflex		\| other_names = Mass reflex
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	\| image =		\| image =
	\| caption =		\| caption =
	}}		}}'''Autonomic dysreflexia''' is potentially life threatening sympathetic hyperactivity which can emerge following spinal cord injury, and involves dysregulation of the autonomic nervous system leading to a disorganized response to noxious stimulus below the level of the spinal cord injury.

	==Anesthetic implications<!-- Briefly summarize the anesthetic implications of this comorbidity. -->==		==Anesthetic implications<!-- Briefly summarize the anesthetic implications of this comorbidity. -->==

Chris.Rishel: Added draft of infobox content

2021-06-19T10:20:56Z

Added draft of infobox content

← Older revision		Revision as of 03:20, 19 June 2021
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	Autonomic dysreflexia can emerge following spinal cord injury, and involves dysregulation of the autonomic nervous system leading to a ~~potentially life threatening~~ disorganized response to noxious stimulus below the level of the spinal cord injury.		'''Autonomic dysreflexia''' is potentially life threatening sympathetic hyperactivity which can emerge following spinal cord injury, and involves dysregulation of the autonomic nervous system leading to a disorganized response to noxious stimulus below the level of the spinal cord injury.

	{{Infobox comorbidity		{{Infobox comorbidity
	\| other_names =		\| other_names = Mass reflex
	\| anesthetic_relevance =		\| anesthetic_relevance = Critical
	\| specialty =		\| anesthetic_management = Consider neuraxial or MAC<br/>
	\| signs_symptoms =		If GA, run deep
	\| diagnosis =		\| specialty = Neurology, Cardiology
	\| treatment =		\| signs_symptoms = Hypertension<br/>
			Headache<br/>
			Diaphoresis<br/>
			Bradycardia or tachycardia
			\| diagnosis = Most common with lesions above T6.
			Has been described in lesions as low as T10
			\| treatment = Rapidly titratable vasodilators
			Deepen anesthesia
	\| image =		\| image =
	\| caption =		\| caption =
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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. -->==
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	[[Category:Comorbidities]]		[[Category:Comorbidities]]

			<references />

Mitchel.DeVita: Started page, added signs and symptoms, preop and intraop management

2021-06-18T18:49:58Z

Started page, added signs and symptoms, preop and intraop management

New page

Autonomic dysreflexia can emerge following spinal cord injury, and involves dysregulation of the autonomic nervous system leading to a potentially life threatening disorganized response to noxious stimulus below the level of the spinal cord injury.

{{Infobox comorbidity
| other_names =
| anesthetic_relevance =
| specialty =
| signs_symptoms =
| diagnosis =
| treatment =
| image =
| caption =
}}

==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. <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===

==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==

[[Category:Comorbidities]]

← Older revision		Revision as of 03:27, 19 June 2021
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	\| image =		\| image =
	\| caption =		\| caption =
	}}'''Autonomic dysreflexia''' is potentially life threatening sympathetic hyperactivity which can emerge ~~following spinal cord injury, and involves dysregulation of the autonomic nervous system leading to a disorganized~~ response to noxious ~~stimulus~~ below the level of ~~the~~ spinal cord injury.		}}'''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 -->===