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Autonomic Dysreflexia

Prevention of AD During Bladder Procedures

Urinary bladder irritation or stimulation is the major trigger of AD following SCI (McGuire & Kumar, 1986Linsenmeyer et al. 1996Giannantoni et al. 1998Teasell et al. 2000; Mathias & Frankel 2002). A bladder management program and continuous urological follow-up are important elements of the medical care of individuals with SCI (Waites et al. 1993aVaidyanathan et al. 1994Vaidyanathan et al. 2004). An established bladder management program with intermittent catheterization or an indwelling Foley catheter allows individuals with SCI to plan for bladder emptying when convenient or necessary (Consortium for Spinal Cord Medicine 2006). However, there are no studies that specifically assess the effect of bladder management programs on the rate of occurrence of autonomic dysreflexia.

During the last decade, urological follow-up including annual urodynamic evaluations and cystoscopy (depending on the bladder management program), have decreased the frequency of urinary tract infections and the development of renal failure in individuals with SCI (Waites et al. 1993aWaites et al. 1993bDeVivo et al. 1999). However, conservative management is not always successful and alternative strategies (e.g. application of Botulinum toxin, capsaicin, anticholinergics, sacral denervation and bladder and urethral sphincter surgery) are sometimes needed to decrease afferent stimulation from the urinary bladder to prevent development of AD. In addition, urodynamic procedures and cystoscopy are associated with significant activation of urinary bladder afferents and have the potential to trigger AD (Linsenmeyer et al. 1996Dykstra et al. 1987Snow et al. 1978Chancellor et al. 1993) and therefore also require strategies to reduce afferent stimulation during those procedures.

Author Year;
Country Score
Research Design
Sample Size
Methods Outcome

Xiong et al. 2015; China
Case Series
N=89

Population: 89 SCI cases with bladder stones undergoing cystolitholapaxy
64 males, 25 females
Mean (SD) age in years = 35.98 (8.17)
Injury level: 57 subjects above T6
Treatment: 48 with with spinal anesthesia, 26 with general anesthesia, 15 with local anesthesia
Outcome Measures: Presence of AD, stone size and number, length of surgery
  1. Of the 89 patients, 31 (34.83%) developed AD during the operation
  2. Patients with AD had larger stones (4.58+/-1.26 cm vs. 3.75+/-1.15cm) and a higher number of stones (2.29+/-0.86 vs. 1.74+/-0.81)
  3. 83.87% of patients with AD had lesion level at or above T6 vs. 41.38% in non AD group
  4. Operation time was longer in AD group vs. non AD group (60.65+/-17.78 min vs. 49.31+/-14.31 min)
  5. Incidence rate of AD was highest in patients with local anesthesia (18/20, 90%), followed by general anesthesia (12/27, 44.44%) and spinal anesthesia (1/40, 2.5%)

Discussion

One case series (n=89) (Xiong et al. 2015) revealed that individuals experiencing AD during cystolitholapaxy had larger bladder stones, a higher number of bladder stones, and longer operation time. Spinal anesthesia may be the most effective way to prevent incidence of AD in cystolitholapaxy procedures as only 2.5% of participants with spinal anesthesia experienced AD.

Conclusion

There is level 4 evidence (from one case series: Xiong et al. 2015) that spinal anesthesia may be more effective at preventing incidence of AD during cystolitholapaxy compared to local or general anesthesia.

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