Vaidyanathan Subramanian, Soni Bakul, Selmi Fahed, Singh Gurpreet, Esanu Cristian, Hughes Peter, Oo Tun, Pulya Kamesh
Regional Spinal Injuries Centre, Southport and Formby District General Hospital, Town Lane, Southport PR8 6PN, UK.
Patient Saf Surg. 2012 Feb 20;6:3. doi: 10.1186/1754-9493-6-3.
Some tetraplegic patients may wish to undergo urological procedures without anaesthesia, but these patients can develop autonomic dysreflexia if cystoscopy and vesical lithotripsy are performed without anaesthesia.
We describe three tetraplegic patients, who developed autonomic dysreflexia when cystoscopy and laser lithotripsy were carried out without anesthesia.In two patients, who declined anaesthesia, blood pressure increased to more than 200/110 mmHg during cystoscopy. One of these patients developed severe bleeding from bladder mucosa and lithotripsy was abandoned. Laser lithotripsy was carried out under subarachnoid block a week later in this patient, and this patient did not develop autonomic dysreflexia.The third patient with C-3 tetraplegia had undergone correction of kyphoscoliotic deformity of spine with spinal rods and pedicular screws from the level of T-2 to S-2. Pulmonary function test revealed moderate to severe restricted curve. This patient developed vesical calculus and did not wish to have general anaesthesia because of possible need for respiratory support post-operatively. Subarachnoid block was not considered in view of previous spinal fixation. When cystoscopy and laser lithotripsy were carried out under sedation, blood pressure increased from 110/50 mmHg to 160/80 mmHg.
These cases show that tetraplegic patients are likely to develop autonomic dysreflexia during cystoscopy and vesical lithotripsy, performed without anaesthesia. Health professionals should educate spinal cord injury patients regarding risks of autonomic dysreflexia, when urological procedures are carried out without anaesthesia. If spinal cord injury patients are made aware of potentially life-threatening complications of autonomic dysreflexia, they are less likely to decline anaesthesia for urological procedures. Subrachnoid block or epidural meperidine blocks nociceptive impulses from urinary bladder and prevents occurrence of autonomic dysreflexia. If spinal cord injury patients with lesions above T-6 decline anaesthesia, nifedipine 10 mg should be given sublingually prior to cystoscopy to prevent increase in blood pressure due to autonomic dysreflexia.
一些四肢瘫痪患者可能希望在不进行麻醉的情况下接受泌尿外科手术，但如果在不麻醉的情况下进行膀胱镜检查和膀胱碎石术，这些患者可能会发生自主神经反射异常。
我们描述了3例四肢瘫痪患者，他们在未进行麻醉的情况下进行膀胱镜检查和激光碎石术时发生了自主神经反射异常。在2例拒绝麻醉的患者中，膀胱镜检查期间血压升至200/110 mmHg以上。其中1例患者膀胱黏膜严重出血，碎石术被迫放弃。1周后该患者在蛛网膜下腔阻滞下进行激光碎石术，未发生自主神经反射异常。第3例C-3四肢瘫痪患者曾接受从T-2至S-2节段的脊柱后凸侧弯畸形矫正术，使用了脊柱棒和椎弓根螺钉。肺功能测试显示为中度至重度限制性曲线。该患者发生膀胱结石，因术后可能需要呼吸支持而不希望进行全身麻醉。鉴于先前的脊柱固定情况，未考虑蛛网膜下腔阻滞。在镇静下进行膀胱镜检查和激光碎石术时，血压从110/50 mmHg升至160/80 mmHg。
这些病例表明，四肢瘫痪患者在未麻醉的情况下进行膀胱镜检查和膀胱碎石术时很可能发生自主神经反射异常。卫生专业人员应在未麻醉进行泌尿外科手术时，对脊髓损伤患者进行关于自主神经反射异常风险的教育。如果脊髓损伤患者了解自主神经反射异常可能危及生命的并发症，他们就不太可能拒绝泌尿外科手术的麻醉。蛛网膜下腔阻滞或硬膜外注射哌替啶可阻断来自膀胱的伤害性冲动，防止自主神经反射异常的发生。如果T-6以上节段损伤的脊髓损伤患者拒绝麻醉，应在膀胱镜检查前舌下含服硝苯地平10 mg，以防止因自主神经反射异常导致血压升高。
