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Prevention of AD during General Surgery

Despite the partial or total loss of sensation below the level of injury, surgical procedures or manipulations can potentially initiate episodes of AD. Anesthesiologists and surgeons performing surgery on SCI patients must be aware of the interactions of the anesthetic and its effects on AD and how to prevent or manage AD during these procedures.

 

Table 11: Prevention of AD during Surgery

Author Year; Country
Score
Research Design
Sample Size
MethodsOutcome
Eltorai et al. 1997; USA

Observational

N=591

Population: Level of injury: C1-T10, mean length of injury: 22.3 yrs.

Treatment: retrospective review of anesthetic methods during surgery.

Outcome Measures: blood pressure.

1.     AD occurred most commonly during the start of anesthesia (induction) with the greatest frequency when no anesthesia was provided.

2.     During induction, systolic blood pressure increased in 68.7% of procedures during combined local anesthesia and intravenous (IV) sedation, in 65.4% of IV sedation alone, in 62.1% of local anesthesia alone, in 51.5% of spinal or epidural anesthesia, in 51.5% of general anesthesia, and in 88.8% of no anesthesia.

Lambert et al. 1982; USA

Observational

N=50

Population: Subjects had injuries that were above T6, and complete; mean of 6.5 years post-injury.

Treatment: Retrospective review of 78 procedures. Three groups:

1) topical or no anesthesia sedation (n=19), 2) general anesthesia (n=13), and;

3) spinal anesthesia (n=46).

Outcome Measures: blood pressure.

1.     Intraoperative hypertension occurred more significantly with topical or no anesthesia (15/19) compared to general anesthesia (3/13) or spinal anesthesia (3/46).

2.   Intraoperatively systolic BP increased significantly by 37 mmHgg (p<0.005), but declined in the general and spinal anesthesia groups.  in patients receiving topical or no anesthesia. No significant difference in BP changes between general and spinal anesthesia groups.

Two observational studies (Lambert et al. 1982; Eltorai et al. 1997) presented evidence that AD is a common complication during general surgery in individuals with SCI. Up to 90% of individuals undergoing surgery with topical anesthesia or no anesthesia developed AD. Both studies concluded that patients at risk for AD could be protected by either general or spinal anesthesia.

Discussion

Two observational studies (Lambert et al. 1982; Eltorai et al. 1997) presented evidence that AD is a common complication during general surgery in individuals with SCI. Up to 90% of individuals undergoing surgery with topical anesthesia or no anesthesia developed AD. Both studies concluded that patients at risk for AD could be protected by either general or spinal anesthesia.

Conclusion

There is level 5 evidence (from 2 observational studies) (Lambert et al. 1982; Eltorai et al. 1997) that indicates that patients at risk for autonomic dysreflexia are protected from developing intraoperative hypertension by either general or spinal anesthesia.

  • Anesthesiologists and surgeons dealing with SCI patients must know how to recognize the AD syndrome, how to prevent its occurrence and how to manage it.

    Anesthesia should be used during surgical procedures in individuals with SCI despite apparent lack of sensation.