Question about autonomic hyperreflexia

[ilikeburgers]

Let's say theres a patient who is quadriplegic from a spinal cord injury 30 years ago, coming in for a cystoscopy. Would you do the case under a MAC with minimal sedation, or are you worried about autonomic hyperreflexia?

My question is how long after a spinal cord injury is a patient at risk for autonomic hyperreflexia? I was told by someone that after 10+ years, the risk goes away. But I tried to do some research online, and I couldn't find anything about that. Anyone here know the answer?

Thanks!

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[pgg]

Good question. I was under the impression that the risk never becomes negligible. I can't find any reference declaring it to be a non-risk after X amount of time.

There's a report of it happening 13 years after injury - this was referenced in another article but I dont have access to look it up just now. Colachis SC. Autonomic hyperreflexia with spinal cord injury. J Am Paraplegia Soc, 1991; 15: 171–186.

As for the claim that the risk drops to near zero after about 10 years, I would wonder about survivorship bias affecting that risk assessment.

I don't think I'd blow it off. I'd treat the guy as if he was at risk.

 

[Noyac]

Without being too rude here I would like to say, do your own research and I don’t mean on the internet. Don’t rely on an anonymous Internet forum to educate you. That is lazy and just plain stupid. Autonomic Hyperreflexia is extremely well described in text books which by the way you should be reading.

My only comment is that pts who suffer from AH will describe it pretty well. Mostly when they have a full bladder. Take an accurate H&P. Another lost art of young docs.

 

[caligas]

Without being too rude here I would like to say, do your own research and I don’t mean on the internet. Don’t rely on an anonymous Internet forum to educate you. That is lazy and just plain stupid. Autonomic Hyperreflexia is extremely well described in text books which by the way you should be reading.

My only comment is that pts who suffer from AH will describe it pretty well. Mostly when they have a full bladder. Take an accurate H&P. Another lost art of young docs.

I’m not disagreeing with you but I would add that this forum is useful for getting a “real world” perspective that is not available in the books or literature. Maybe the OP should first mention what they found in the literature in asking the question.

 

[caligas]

I saw it once trying to do propofol sedation for a Cysto with a t8 transection. Don’t remember how old the cord injury was but I definitely remember the systolic BP of 250. Never again.

 

[Noyac]

I’m not disagreeing with you but I would add that this forum is useful for getting a “real world” perspective that is not available in the books or literature. Maybe the OP should first mention what they found in the literature in asking the question.

True but posting that “I was told by someone” is not a good way to start.

 

[lobelsteve]

Spinal cord injury is the purview of physical medicine and rehabilitation. It would probably be an excellent question to post in their forum.

 

[deleted697535]

I saw it once trying to do propofol sedation for a Cysto with a t8 transection. Don’t remember how old the cord injury was but I definitely remember the systolic BP of 250. Never again.

T8 is fairly low to get it.
It's usually t6 or above.

Bladder type ops in people with ADR can be a potential stimulus for it but some ops can be done just anaestheist on standby.
A spinal can be done tóo. Low dose and you're sorted.


If you do get it make sure you're handy with gtn, phentolamine and emptying that bladder asap

I would've thought that this would be extensively examined in the boards exam? Along with thyroid storm and phaeo and turp syndrome it's so common on exams

 

[ilikeburgers]

Wow, I didn't think I would get this kind of response on this forum for posting an honest question...

I did look in a textbook, and I couldn't find the answer to my specific question, which was if the risk of autonomic hyperreflexia goes away after a certain amount of time after the spinal cord injury. And I looked on Up to Date, and I also asked some of my colleagues, and still couldn't get a clear answer. Which is why I asked it here. And that "someone" is one of my attendings who gave a lecture when I was in residency. I don't keep in touch with him anymore.

Anyway, Noyac thanks for reminding me why I don't come to this forum anymore. It's sad that I can't even post this kind of question without getting attacked and insulted, accused of being lazy and stupid. Goodbye, SDN.

 

[deleted162650]

 

[GaseousClay]

Wow, I didn't think I would get this kind of response on this forum for posting an honest question...

I did look in a textbook, and I couldn't find the answer to my specific question, which was if the risk of autonomic hyperreflexia goes away after a certain amount of time after the spinal cord injury. And I looked on Up to Date, and I also asked some of my colleagues, and still couldn't get a clear answer. Which is why I asked it here. And that "someone" is one of my attendings who gave a lecture when I was in residency. I don't keep in touch with him anymore.

Anyway, Noyac thanks for reminding me why I don't come to this forum anymore. It's sad that I can't even post this kind of question without getting attacked and insulted, accused of being lazy and stupid. Goodbye, SDN.

i agree with you, I don't see anything wrong with him asking this question Noyac. Your reply was actually pointless and unncessary. Its actually a pretty unclear answer and there is nothing definitive in textbooks or literature. I would err on the side of caution and treat all T6 or above spinal cord patients the same regardless of duration.

 

[pgg]

Wow, I didn't think I would get this kind of response on this forum for posting an honest question...

I did look in a textbook, and I couldn't find the answer to my specific question, which was if the risk of autonomic hyperreflexia goes away after a certain amount of time after the spinal cord injury. And I looked on Up to Date, and I also asked some of my colleagues, and still couldn't get a clear answer. Which is why I asked it here. And that "someone" is one of my attendings who gave a lecture when I was in residency. I don't keep in touch with him anymore.

Anyway, Noyac thanks for reminding me why I don't come to this forum anymore. It's sad that I can't even post this kind of question without getting attacked and insulted, accused of being lazy and stupid. Goodbye, SDN.

About 10 replies to your question, one of which you didn't like, and you're leaving? That's pretty thin skinned, but OK.

 

[Aether2000]

Ok, how about a patient with a T4 complete lesion that became complete 25 years ago (spina bifida) with anesthesia and paraplegia below that level without a history of AH, coming in for an extensive sacral decub debridement due to infection. How would you handle it?

 

[deleted697535]

If patient wants a ga then ga with art line, urinary catheter, gtn ready

If they don't want a ga then 1cc of 0.5% heavy bupi spinal unless they're really septic and dry

If they've had this for 25 years they prob have had an anaesthetic before so read that too

 

[Noyac]

Ok, how about a patient with a T4 complete lesion that became complete 25 years ago (spina bifida) with anesthesia and paraplegia below that level without a history of AH, coming in for an extensive sacral decub debridement due to infection. How would you handle it?

Now that’s a better question.
I would dig deep into their history regarding sign and symptoms of AD. Most of these pts are tuned in to the symptoms, headache, flushed, diaphoretic.
If so, I would do a spinal.
If no s/s, then a GA or even MAC may be appropriate. But I am very cautious with these pts. I treat them all as if they have AD. I have had two case, both urologic case, in which AD came on and it isn’t fun. Very very rocky course.

 

[IlDestriero]

About 10 replies to your question, one of which you didn't like, and you're leaving? That's pretty thin skinned, but OK.

With 14 posts in almost a decade including 2 here, I’m not sure we’ll be missing much.
Having said that, it seems like high risk low reward to avoid a spinal or ga.
Throw in a real difficult airway, Critical AS, recent MI or CVA, etc. and maybe the risk/benefit ratio starts to shift around.


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Il Destriero