Background: Autonomic hyperreflexia (AHR) is a potentially life-threatening hypertensive condition that develops in patients with spinal cord injury (SCI) above T6 level as a result of exaggerated spinal sympathetic excitation. AHR is tipically precipitated by distension of the bladder or rectum.1 There are reports that lidocaine (Ld) anal block significantly limits the AHR response in susceptible patients undergoing anorectal procedures2 and cases of AHR treated successfully with epidural Ld.1
Case report: A 44yr-old male,with a SCI at T4,was scheduled for elective cystoscopy. The patient had no history of AHR in several years before this surgery.
In the operating room, patient was reluctant to have general anesthesia. Subarachnoid block was technically difficult in the previous surgery and he had thrombocytopenia (98.000). He underwent sedation and analgesia (S&A) with midazolam 2mg iv, fentanyl 0,1 mg iv, acetaminophen 1g iv and ketorolac 30mg iv.
Prior to the introduction of the cystoscopy, blood pressure (BP) was 131/76mmHg and heart rate (HR) was 78bpm (normal sinus rhythm).
After distension of the bladder, BP increased to 194/125mmHg and severe bradycardia occurs (30bpm). Atropine 0.5+0.5mg ivwas given. BP continues to rise to 200/126mmHg and tachycardia occurs (118bpm) with ventricular bigeminy. The patient complained of severe headache. Fentanyl 0,1 mg + midazolam 2mg were administered. Therefore, 80mg of iv Ld was given.
About 3 min later, there was complete resolution of symptoms, with BP and HR return to baseline.The surgery lasted 25min and the patient went to the PACU hemodynamically stable. He was discharged home in first postoperative day, and no sequelae were noted.
Discussion: This case reports a serious condition in a SCI patient, demonstrating that these patients are likely to develop AHR during cystoscopy performed under S&A. To date, there is no consensus regarding anesthesia management of these patients.3 Many anesthetic techniques have been proposed and used with varying success,but none of them is uniformly successful.3 To our knowledge, this is the first case report of severe AHR treated successfully with iv Ld.
1. Anesth Analg 1999;89:148-9
2. Dis Colon Rectum. 2005 Aug;48(8)
3. Acta Anaesthesiol.Sin 1999 Mar;37(1):29-34.
Learning points: Health professionals should educate SCI patients regarding risks of AHR and possible life-threatening complications, if urologic procedures are carried out under S&A.