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Chronic tetraplegia for pressure ulcer flap: autonomic dysreflexia29-year-old woman, 52 kg, with complete C6 tetraplegia from a car crash 6 years ago

From memory: the diagnosis and the notes are hidden. Answer each question aloud, then press Show.

Know this first

  • Dysreflexia occurs with lesions at or above T6; about 85% of those above T6.
  • Diagnosed by systolic more than 20 mmHg above baseline, with headache, flushing, slow pulse.
  • Insensate patients still need anaesthesia to block the reflex.
  • Spinal prevents it more reliably than epidural.
  • Short-acting vasodilator ready; no suxamethonium in chronic injury.

The patient

29-year-old woman, 52 kg, with complete C6 tetraplegia from a car crash 6 years ago. Recurrent autonomic dysreflexia with bladder spasms; usual BP 92/56; two chest infections this year; weak cough, VC 1.6 L. For elective debridement and flap of a sacral pressure ulcer, prone. Drugs: baclofen, oxybutynin, intermittent self-catheterisation. Vitals: BP 94/58, HR 62, SpO2 96% on air, RR 16, temperature 36.2 °C.

The examiner asks

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  1. Consider

    What are the key issues?

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    • A 29-year-old with complete C6 tetraplegia and recurrent dysreflexia, for prone sacral flap surgery. Patient
    • Complete lesion above T6: her dysreflexia risk is high. Disease
    • Her usual systolic is 92, so a reading that looks normal may already be a surge.
    • Triggers below her lesion: bladder, bowel, the ulcer and the surgery itself. Stem trigger
    • Weak cough and two chest infections: her respiratory reserve is poor. Disease
    • Baclofen continues; stopping it suddenly can cause withdrawal seizures.

  2. Prepare

    How do you prepare her?

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    • She can't feel the area, but still needs anaesthesia to block the reflex. Disease
    • Bladder and bowel emptied before we start. Stem trigger
    • Arterial line; clevidipine or nitroglycerin ready for a surge. Crisis
    • Spinal blocks the reflex more reliably than epidural; GA works too. Disease
    • No suxamethonium; rocuronium if she needs a relaxant.
    • Pressure points padded and active warming; she can't regulate temperature.

  3. Plan

    What is your anaesthetic plan?

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    • GA with an adequate depth before incision; a spinal if she prefers and it's feasible. Disease
    • Never light at incision: deepen before any stimulus. Stem trigger
    • Prone, with the wound below her lesion, so the trigger lasts all case. Surgery
    • Dysreflexia may first appear in recovery as the anaesthetic wears off. After surgery
    • Extubate fully awake; physiotherapy and assisted cough after.

  4. Crisis

    At incision, BP rises to 196/110 and HR falls to 44; her face is flushed. What do you do?

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    • Autonomic dysreflexia, triggered by incision below her lesion. (Crisis)
    • Remove the stimulus: surgeon pauses; I check her catheter for kinks or blockage.
    • Deepen the anaesthetic.
    • Direct vasodilator: clevidipine 100–250 mcg or nitroglycerin 50–100 mcg IV.
    • If it persists, an infusion: clevidipine 2–21 mg/h.
    • Her slow pulse is a baroreflex response; treat the pressure, not the rate.
    • Untreated, it can cause seizures, intracranial bleeding or infarction.

  5. Crisis

    In recovery after extubation she becomes drowsy; RR 30 and shallow, ETCO2 62 mmHg, SpO2 90%. What do you do?

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    • Hypoventilation: no intercostals, a weak cough, and residual drugs. Crisis
    • Sit her up, give oxygen, check for residual block and opioid.
    • Naloxone 40 mcg every 2 min if opioid is contributing.
    • Assisted cough and suction, oxygenated first so suction doesn't slow her heart.
    • Still tiring: non-invasive support or reintubation in ICU. After surgery

Fatal mistakes

  • No anaesthetic because she's insensate.
  • Suxamethonium in chronic cord injury.
  • Ignoring headache and flushing.

Checked against: Evaluation and management of autonomic dysreflexia and other autonomic dysfunctions (2020) · Stoelting 8e · Miller 10e · Barash 9e

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Same topic, another patient

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Another patient · Obstetric anaesthesia. High thoracic spinal cord injury in labour. Same dysreflexia in labour: early epidural, telling it from preeclampsia

Know this first

  • Injury at T6 or above: risk of autonomic dysreflexia.
  • Lesions above T10: labour may be painless.
  • Neuraxial block is the most reliable prevention of dysreflexia in labour.
  • Dysreflexia rises with contractions and settles between them; preeclampsia does not.
  • Suxamethonium is avoided in chronic cord injury: severe hyperkalaemia.

The patient

32-year-old woman, 58 kg, at 38 weeks with a complete T4 spinal cord injury from a car crash 10 years ago, for induction of labour. Recurrent urinary infections; intermittent self-catheterisation; history of a sacral pressure sore. Drugs: oxybutynin, senna, docusate. Vitals: BP 96/58 (her usual), HR 64, SpO2 97% on air, RR 16.

The examiner asks

Answer aloud, then press Show.

  1. Consider

    What are the issues?

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    • A 32-year-old, complete T4 injury 10 years ago, for induction of labour at 38 weeks. Patient
    • Pregnancy at term still brings aspiration risk, caval compression and a difficult airway.
    • Her lesion is above T6, so autonomic dysreflexia in labour is a real risk. Disease
    • Above T10 she may not feel contractions, so labour can progress unnoticed.
    • Her baseline is 96/58, so a 'normal' 130 systolic may already be a large rise.

  2. Prepare

    How do you prepare her?

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    • Antenatal anaesthetic review; epidural planned for the start of labour. Patient
    • Triggers to avoid: full bladder or bowel, examinations, tight clothing, pressure areas. Disease
    • Indwelling catheter, bowels emptied, careful padding and pressure care.
    • Her breathing reserve checked: a T4 lesion weakens intercostals and cough.
    • Close fetal monitoring and frequent BP checks through labour.

  3. Plan

    What is your plan for her labour?

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    • Early epidural: the most reliable way to block pelvic stimuli and prevent dysreflexia. Disease
    • A block to T10 stops the pelvic trigger; she can't feel it, so calm BP through contractions shows it works.
    • If she needs a general anaesthetic: no suxamethonium, as it causes severe hyperkalaemia in chronic injury. Airway
    • After birth: breastfeeding and engorgement can trigger dysreflexia; thromboprophylaxis too. After surgery

  4. Crisis

    With each contraction her BP rises to 190/110 with a pounding headache, flushing above her chest, and HR 48; between contractions it settles. What do you do?

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    • Autonomic dysreflexia: it surges with contractions and settles between, unlike preeclampsia. (Crisis)
    • Sit her up if possible, legs down; loosen anything tight.
    • Remove the trigger: check the catheter for kinks or blockage, and check the bowel.
    • Dose the epidural now to block the pelvic input.
    • Systolic still 150 or more: a fast, short-acting drug such as nifedipine or nitrate paste.
    • Urine protein and platelets to exclude preeclampsia as well.
    • Untreated, it can cause seizures, intracranial haemorrhage or myocardial infarction.

Fatal mistakes

  • No epidural for labour with a T4 lesion.
  • Treating dysreflexia as preeclampsia only.
  • Suxamethonium in chronic cord injury.

Checked against: Evaluation and management of autonomic dysreflexia and other autonomic dysfunctions (2020) · Barash 9e · Mayo review

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