Anesthesia for cesarean section in a patient with paraplegia resulting from tumour metastases to spinal cord

PURPOSE: Spinal cord injured patients present multiple unique challenges to the anesthesiologist. These include choice of muscle relaxant and management of autonomic hyperreflexia. We report the anesthetic management for Cesarean delivery in a patient who was paraplegic due to spinal canal metastases. Preeclampsia and fever complicated this case. CLINICAL FEATURES: The patient presented at 29 wk gestation with progressive paraplegia at the T10 level due to metastatic osteosarcoma. She had a decompressive laminectomy without improvement in her paralysis. She subsequently developed preeclampsia at 31 wk gestation, and underwent Cesarean delivery for breech presentation under general anesthesia. Anatomical concerns left us unsure of the efficacy or safety of neuraxial anesthesia. CONCLUSIONS: Preeclampsia and autonomic hyperreflexia are generally indications for regional anesthesia for Cesarean section. Tumour in her spinal canal and laboratory abnormalities including thrombocytopenia and a potential urosepsis dissuaded us from this option. Additionally, rapid sequence induction and intubation were not preferred due to paraplegia, leading us to secure the airway fibreoptically.     

Autonomic hyperreflexia. A serious complication of radiological procedures in patients with cervical or upper thoracic spinal cord lesions

Autonomic hyperreflexia is a reflex response to visceral distension which occurs only in patients with spinal cord lesions above T6. The marked hypertension, which is an integral part of this reflex, may lead to severe morbidity, or even death. The mechanism whereby interruption of the sympathetic outflow from the spinal cord results in autonomic hyperreflexia is described, as well as the clinical signs and symptoms associated with this condition. The value of autonomic hyperreflexia as a clinical indicator of complications in patients with spinal cord lesions is stressed. The diagnosis and treatment of autonomic hyperreflexia which has occurred as a complication of radiological procedures are discussed.     

Labor management using epidural anesthesia in a gravida patient with high spinal injury

Since autonomic hyperreflexia (AH) is a serious complication during labor in a gravida with spinal cord injury, anesthetic measures should be taken for the suppression of AH even in a sensory-loss condition. Several reports have described various methods for the suppression of AH, in which epidural anesthesia has been advocated as a useful means for the prevention or amelioration of AH. However, it is difficult to evaluate the efficacy of epidural anesthesia due to the lack of sensory and motor functions. We report a primipara who had spinal cord injury below the T 3 level at the age of 17 due to a traffic accident and underwent successful vaginal delivery twice under epidural anesthesia at the ages of 30 and 32. For the first delivery, we placed two epidural catheters. We controlled the rate and the content of epidural infusion through the two different injection sites so as to meet delivery process. For the second delivery we did epidural anesthesia in the same way. Tubal-ligation was also performed under epidural anesthesia after the second delivery. No major obstetric complication including AH occurred in either of delivery. The woman with high spinal injury could have two healthy children without major complications during labor by the cooperation of gynecologists and anesthesiologists.     

Autonome Hyperreflexie,Schwangerschaft und Entbindung bei Para-/Tetraplegie Geburtshilflich-anästhesiologische Gesichtspunkte anhand einer Kasuistik

Although still rare, pregnancy and delivery in women with spinal cord injuries is becoming more frequent (Table 2). In 85%–90% of patients with lesions above T6 symptoms of autonomic hyperreflexia (Table 1), especially paroxysmal and excessive increases in arterial blood pressure, may occur. In anaesthesising a 31-year-old paraplegic primigravida with a complete transverse spinal lesion at T4 for an elective caesarean section, no indication of hypertonic cardiovascular dysregulation either intra- or postoperatively was observed after repeated epidural administration of bupivacaine. Distinct intraoperative spasticity of the abdominal wall muscles was, however, not influenced by the dosages selected.     

Obstetrical anaesthesia and analgesia in chronic spinal cord-injured women

Improved acuteand rehabilitativecareand emphasis on integrating patients into society after spinal cord injury is likely to result in increasing numbers of cord-injured women presenting for obstetrical care. Anaesthetists providing care to these women should be familiar with the complications resulting from chronic cord injury and aware that many may be aggravated by the physiological changes of normal pregnancy. These complications include reduced respiratory volumes and reserve, decreased blood pressure and an increased incidence of thromboembolic phenomena, anaemia and recurrent urinary tract infections. Patients with cord lesions above the T₅ spinal level are at risk for the life-threatening complication of autonomic hyperreflexia (AH) which results from the loss of central regulation of the sympathetic nervous system below the level of the lesion. Sympathetic hyperactivity and hypertension result in response to noxious stimuli entering the cord below the level of the lesion. Labour appears to be a particularly noxious stimulus and patients with injuries above T₅ are at risk for AH during labour even if they have not had previous AH episodes. Morbidity is related to the degree of hypertension and intracranial haemorrhage has been reported during labour and attributed to AH. We report our experience in providing care to three parturients with spinal cord injuries. Two patients had high cervical lesions, one of whom experienced AH during labour and was treated with an epidural block. The second was at risk for AH having had episodes in the past and received an epidural block to provide prophylaxis for AH. In both cases epidural blockade provided effective treatment and prophylaxis for AH. The third patient had alow thoracic cord lesion, a comfortable labour but required an urgent Caesarean section performed under general anaesthesia for placental abruption and antepartum haemorrhage. The outcome of all three maternal-neonatal pairs was excellent. We recommend antepartum anaesthesia consultation for all cordinjured mothers and an epidural block as prophylaxis against AH in all parturients with cord lesions at T₅ or above.     

Anesthetic management of a patient with chronic high spinal cord injury (second report)

We administered anesthesia twice to a 43-year-old male patient with complete sensory and motor disturbance below the upper thoracic nerves due to chronic high spinal cord injury. The first operation was the gluteus maximus musculocutaneous flap for closure of a sacral decubitus ulcer under general anesthesia. The second was the transurethral lithotripsy for the bladder stone under spinal anesthesia. Severe hypertension occurred probably due to autonomic hyperreflexia (AH) during both operations. Therefore, we must be careful in anesthetic management of patients with chronic high spinal cord injury, because AH might occur in any anesthetic administration.     

Effect of autonomic hyperreflexia on plasma benin

Four patients with paroxysmal hypertension related to spinal cord injury (autonomic hyperreflexia) were studied to determine if the plasma renin became elevated in relation to a sympathetic stimulus. Using bladder distention to produce the autonomic hyperreflexia, renin determinations were made during and after the hypertensive episode. None of the patients demonstrated elevation of the plasma renin after this event.     

Anesthetic management of parturients with pre-existing paraplegia or tetraplegia: a case series

With improvements in management and rehabilitation, more women with spinal cord injury are conceiving children. Physiologic manifestations of spinal cord injury can complicate anesthetic management during labor and delivery. Patients who delivered at Mayo Clinic, Rochester, Minnesota between January 1, 2001 and May 31, 2012 with a history of traumatic spinal cord injury were identified via electronic record search of all parturients. Eight patients undergoing nine deliveries were identified. Six deliveries (67%) among five patients (63%) involved a trial of labor. Among these deliveries, three (50%) occurred vaginally, all with successful epidural analgesia. Trial of labor failed in the remaining three patients, and required cesarean delivery facilitated via epidural (n=1), spinal (n=1) and general anesthesia (n=1). Three patients (33%) underwent scheduled cesarean delivery via epidural (n=1), spinal (n=1), and general anesthesia (n=1). Four patients having five deliveries had a history of autonomic hyperreflexia before pregnancy. One patient had symptoms during pregnancy, two patients had episodes during labor and delivery, and three patients described symptoms in the immediate postpartum period. These symptoms were not reported by any patient without a history of autonomic hyperreflexia. Neuraxial labor analgesia may have a higher failure rate in patients with spinal cord injury, possibly related to the presence of Harrington rods. Postpartum exacerbations of autonomic hyperreflexia are common in patients with a history of the disorder.     

Autonomic hyperreflexia after spinal cord injury managed successfully with intravenous lidocaine: a case report

Background

Some paraplegic patients may wish undergo some surgical procedures, like urological procedures, without anesthesia. However, these patients can develop autonomic hyperreflexia if cystoscopy is performed without anesthesia.

Case presentation

We present a case of severe autonomic hyperreflexia in a 44-year-old male with spinal cord injury at the level of T4 during urologic procedure under sedation and analgesia successfully treated with intravenous lidocaine.

Conclusions

This case illustrates that patients with spinal cord injuries are likely to develop autonomic hyperreflexia during urological procedures performed without anesthesia. Health professionals should educate spinal cord injury patients regarding risks of this serious condition and be aware to prevent and manage autonomic hyperreflexia. In an acute episode, nifedipine, nitrates and captopril are the most commonly used and recommended agents. To our knowledge, this is the first case report of severe autonomic hyperreflexia treated successfully with intravenous lidocaine.

     

Autonomic hyperreflexia in spinal cord injury patient during percutaneous nephrolithotomy for renal stone: a case report

Autonomic hyperreflexia or autonomic dysreflexia is a syndrome seen in approximately 85% of all quadriplegic patients and constitutes the only medical emergency related to spinal cord injury. We report on a paraplegic patient with a C5 to C7 spinal cord injury who suffered autonomic hyperreflexia during percutaneous nephrolithotomy for a right renal stone. The reflex-induced hypertension subsided with termination of the operation, and administration of an alpha and beta-adrenergic blocking agent (labelatol hydrochloride). The stone was removed successfully by pyelolithotomy with the patient under general anesthesia 4 days later.     

Paraplegia and pregnancy: anaesthesic management

Pregnancy is a rare occurrence in patient suffering from spinal cord lesion. The authors report the case of labour and delivery in a paraplegic patient who was suffering from lesion located T6 level. In early labour epidural analgesia was maintained and the vaginal delivery was successful without associated fluctuation of blood pressure or other signs of autonomic hyperreflexia. The epidural catheter was maintained for 48 h post-partum. The main risks and anaesthesic management of pregnancy in paraplegic patients are discussed.     

Unique considerations for the spinal cord injured patient undergoing cardiac surgery utilizing cardiopulmonary bypass

A 37-year-old male with mitral valve regurgitation presented for mitral valve replacement. He has been a C5 quadriplegic for 13 years. The patient had been discharged 2 months before to this admission after a complicated hospital course for Staphylococcus aureus infection of the left hip. His course was complicated by adult respiratory distress syndrome (ARDS) requiring prolonged intubation, acute renal failure (ARF) requiring dialysis, 10-day coma, and bacterial endocarditis now requiring mitral valve replacement. After initial stabilization with antibiotics and gradual improvement of the multiorgan system failure, the patient presented for valve replacement and worsening congestive heart failure (CHF). Para- and quadriplegic patients rarely undergo cardiac surgery requiring cardiopulmonary bypass (CPB). The explanation for this low incidence of heart surgery in this patient population ranges from physiologic changes from the spinal cord injury to their relatively short life span. Therefore, there is no vast knowledge of how these patients with spinal cord injury will physiologically respond to CPB. Chronic paraplegia presents unique anesthetic and perfusion challenges. General anesthesia for a patient with prolonged spinal cord damage can be difficult because of dysreflexia, muscle wasting, and potassium changes with depolarizing muscle relaxants. For the perfusionist, chronic paraplegia also accentuates hemodynamic responses to nonpulsatile flow with low peripheral vascular resistance common and difficult to treat. Dramatic increases in circulating catecholamine levels are a secondary result of the initiation of CPB that can cause a hypo- and hypertensive state. Depending on the level of spinal cord injury, one might expect acute hypo- or hypertension with the various phases of open-heart surgery and CPB. A viscous circle may occur because the hypertensive state is exaggerated because of inhibitory signals not passed below the spinal cord lesion and, therefore, the vasoconstrictive reflex continues unabated. The attack usually occurs abruptly and can lead to cerebrovascular hemorrhage and death if not controlled. Fortunately, we found this patient did not develop mass autonomic dysreflexia and was not difficult to wean from CPB. The problems associated with spinal cord injury present potential complications to this patient population. Numerous triggering mechanisms may lead to a variety of clinical complications. Consideration of a response/ treatment management plan for potential problems must be exercised by the surgical team.     

Anemia in Patients With Traumatic Spinal Cord Injury

ABSTRACT

Anemia is often a complication following spinal cord injury which interferes with the patient's rehabilitation. Hematological profiles of 65 male patients with traumatic spinal cord injury revealed a 52.3% incidence of mild anemia. The age, duration or level of injury had no correlation with the incidence and type of anemia. The anemia was normocytic-normochromic in 32%, normocytic mild hypochromic in 56%, and microcytic hypochromic in 12% of the patients. Factors in pathogenesis included decubitus ulcers, urinary tract infections, acute and chronic blood loss, and folic acid deficiency due to psychosocial maladjustment, alcohol and/or drug abuse. Often, multiple factors were operative in changing proportions. The success of management depends on a careful assessment of causes and removal of inciting factors. The most common type of anemia was that due to chronic disorder, associated with either decubitus ulcers and/or urinary tract infections. Since this type of anemia mimics iron deficiency in presentation it should be differentiated from the latter by evaluation of iron status. Normal hemoglobin levels can be attained only after the chronic disorder is eliminated. Unpredictable fluctuations of hemoglobin level secondary to changes in plasma volume due to autonomic hyperreflexia are common in SCI patients, and should be taken into account for diagnosis and follow-up in therapy.     

Nifedipine pretreatment for prevention of autonomic hyperreflexia during anesthesia-free extracorporeal shock wave lithotripsy.

Nifedipine, a calcium channel blocker, has been used to treat autonomic hyperreflexia in quadriplegics undergoing invasive urological procedures. We present a case of autonomic hyperreflexia triggered by extracorporeal shock wave lithotripsy in which nifedipine was used successfully to treat the hypertensive crisis on 1 occasion and subsequently it was used prophylactically to prevent the crisis in the same patient.     

The Value of Sympathetic Skin Response Recordings in the Assessment of the Vesicourethral Autonomic Nervous Dysfunction in Spinal Cord Injured Patients

Purpose

We assessed the degree of sparing of the descending sympathetic spinal tract and correlated these findings with bladder neck function in spinal cord injured patients.

Materials and Methods

Sympathetic skin responses of the right hand and foot were recorded and compared to the urodynamic findings in 27 spinal cord injured patients.

Results

All tetraplegic and paraplegic patients with a lesion above the T6 level who presented with bladder neck dyssynergia associated with autonomic hyperreflexia had abnormal sympathetic skin responses in the right hand and foot. All patients with a lesion below the T6 and above the T12 levels with an abnormal sympathetic skin response in the right foot also had bladder neck dyssynergia.

Conclusions

Evidence is presented that the integrity of the descending sympathetic spinal tract is necessary for a synergic function of the vesicourethral complex and that sympathetic skin responses are of value in the diagnosis of bladder neck dyssynergia. For lesions below the T12 level other investigative methods to exclude bladder neck dyssynergia are necessary.     

Incidence of Neurologic Complications Related to Thoracic Epidural Catheterization

Background: Due to potential neurologic sequelae, the risk:benefit ratio of thoracic epidural analgesia is controversial. Surprisingly, however, few available data address neurologic complications. The incidence of neurologic complications occurring after thoracic epidural catheterization was studied in patients scheduled for abdominal or abdominothoracic surgery.

Methods: A total of 4,185 patients were studied, including 2,059 during the prospective phase of the study and 2,126 during the retrospective phase. After thoracic epidural catheterization, all patients received general anesthesia. Patients' neurologic status was assessed by an anesthesiologist using clinical criteria after operation and after epidural catheter removal. If neurologic complications were suspected, a neurologist was consulted. The incidence of specific complications was compared for different thoracic puncture sites: upper (T3/4-6/7), mid (T7/8-8/9), and lower (T9/10-11/12) catheter insertion levels.

Results: The overall incidence of complications after thoracic epidural catheterization was 3.1% (n = 128). This included dural perforation (0.7%; n = 30); unsuccessful catheter placement (1.1%; n = 45); postoperative radicular type pain (0.2%; n = 9), responsive to catheter withdrawal in all cases; and peripheral nerve lesions (0.6%; n = 24), 0.3% (n = 14) of which were peroneal nerve palsies probably related to surgical positioning or other transient peripheral nerve lesions (0.2%; n = 10). No signs suggesting epidural hematoma were recognized, and there were no permanent sensory or motor defects attributable to epidural catheterization. Unintentional dural perforation was observed significantly more often in the lower (3.4%) than in the mid (0.9%), or upper (0.4%) thoracic region. A single patient experienced severe respiratory depression after receiving epidural buprenorphine but recovered without sequelae.     

The effect of nifedipine on cystoscopy-induced autonomic hyperreflexia in patients with high spinal cord injuries

We evaluated the ability of the calcium channel blocker nifedipine to control autonomic hyperreflexia during cystoscopy in 7 patients with cervical spinal cord injuries. Nifedipine (10 mg.) alleviated autonomic hyperreflexia when given sublingually during cystoscopy and prevented autonomic hyperreflexia when given orally 30 minutes before cystoscopy. No adverse drug effects were observed.     

Autonomic Hyperreflexia With Spinal Cord Injury

ABSTRACT

Autonomic hyperreflexia occurs in up to 85 percent of individuals with spinal cord injuries above the major splanchnic sympathetic outflow. In such cases, paroxysmal reflex sympathetic activity develops in response to noxious stimuli below the level of the neurologic lesion. The clinical features of autonomic hyperreflexia are due largely to reflex sympathetic adrenergic and cholinergic discharges with dysfunctional supraspinal regulatory control. Cephalgia, diaphoresis, flushing, tachycardia or bradycardia, and paroxysmal hypertension are most commonly observed. Although a variety of stimuli can provoke autonomic responses of variable magnitudes, bladder and bowel distention continue to account for most episodes. Removal of the offending stimulus is important to restoring the autonomic nervous system to its baseline activity. Current understanding of the pathophysiology, clinical features, and medical management of this fascinating but potentially serious complication of spinal cord injury are reviewed.     

Anesthetic Management of Clinically Silent Familial Pheochromocytoma with MEN 2A: A Report of Four Cases

Familial pheochromocytomas are commonly associated with multiple endocrine neoplasia type 2 (MEN 2) syndrome. Majority of the patients present with normal clinical and biochemical parameters in the preoperative period, the incidence of hypertension being only 50 %. Even though patients may be clinically asymptomatic, surveillance and proper preoperative evaluation is important, as surgery for associated tumors may precipitate a hypertensive crisis and result in severe complications. A family of 19 members, of which 12 were positive for MEN 2A syndrome, presented to our hospital. Seven of the 12 patients had pheochromocytoma and medullary thyroid carcinoma (MTC), while the other 5 had only raised plasma calcitonin levels. Two of the 7 patients presented with bilateral pheochromocytoma and underwent an open adrenalectomy. The other 5 patients had a left-sided adrenal tumor and underwent left laparoscopic adrenalectomy under combined general and epidural anesthesia. We present our experience with four of these five cases. We here state that how paucity of literature on perioperative preparation of clinically and biochemically silent pheochromocytomas led to serious intraoperative complications in one of four cases.     

A case of rectal excision in a patient with cervical spinal cord injury of chronic stage

A 63-year-old man, scheduled for a Hartmann's procedure, sustained a cervical injury with resultant complete motor and sensory loss below the fourth cervical segment 39 years prior to admission. Anesthesia was induced with propofol 70 mg, vecuronium bromide 5 mg and an endotracheal tube was placed in the trachea. Anesthesia was maintained with nitrous oxide/oxygen and fentanyl. Ventilation was controlled to maintain normocapnea. We did not employ epidual anesthesia due to inability to flex the spine. We administered fentanyl to control hypertension, but it led to hypotension. And about 500 ml of bleeding also caused hypotension. These episodes of hypotension are associated with hypovolemia and instability of vascular tone. To control hypotension, we finally selected continuous intravenous administration of norepinephrine. The manifestations of cardiovascular instability during surgery in chronic stage of cervical spinal cord injury is not only hypertension associated with autonomic hyperreflexia, but also hypotension associated with instability of vascular tone and hypovolemia.