Spinal Anesthesia for Autonomic Dysreflexia Prevention: A Case Report in a Quadriplegic Patient

Sejal J. Shah, MD; Jyoti P. Dangle, MD

 

Introduction:

• Patients with spinal cord injury (SCI) above T6 often suffer from autonomic dysreflexia (AD).

• Perioperative stressors can contribute to these potentially lifethreatening complication such as severe hypertensive response.

• Bradycardia, cardiac arrhythmias and cardiac dysfunction may occur.

 

Case Report:

• 22yo male with PMH of cervical spine injury and incomplete quadriplegia who presents for cystectomy with ileal conduit urinary diversion.

• Experienced severe AD with previous urologic procedure.

• Administered spinal anesthesia (SA) after intubation using 2mL of 0.75% hyperbaric bupivacaine and 0.2mg of morphine.

• Initial sympathectomy from spinal treated with phenylephrine boluses.

• Radial arterial line placed for close hemodynamic monitoring.

• Surgical time of 2 hours and 47 minutes – spinal wore off towards the end with blood pressure trending up.

• 0.25mg of nicardipine was administered at emergence as a precaution.

• Patient was successfully extubated to 4L nasal cannula with no hemodynamic swings and no vasodilator infusion requirement.

 

Discussion:

• AD intraoperatively increases the risk of cerebral hemorrhage and cardiac arrest.

•We demonstrated the successful use of SA in preventing AD intraoperatively.

•Must consider length of surgery – longer cases may warrant intrathecal catheters or epidural.

• Titrating epidural anesthesia to appropriate dermatomal levels can be difficult with a possibility of an incomplete sympathectomy.

• Anticoagulation status and infection risk should also be considered.

• In quadriplegic patients undergoing procedural intervention below the level of their SCI, consider SA to prevent AD.