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doi: 10.1093/bjaceaccp/mku024
Advance Access Publication Date: 9 July 2014
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© The Author 2014. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
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123
Perioperative management for patients with a CSCI
70% in patients with lesions above T64 and increases in frequency exaggerated responses. Activation of the autonomic nervous sys-
with higher level lesions and complete lesions. There are reports tem below the level of the lesion results in a profound sympathet-
of ADR with lesions as low as T10; however, symptoms are less ic response up to the level of injury.
severe in patients with lower lesions. Although it is most com- If the level is above T6, the splanchnic circulation becomes in-
monly observed in the chronic stage of CSI (a year after injury), volved resulting in splanchnic vasoconstriction, and hence, a
early episodes can occur within weeks of injury, and 10% of pa- greater severity of symptoms. Compensatory mechanisms aiming
tients with lesions above T6 experience ADR within first year of to reduce the hypertension, via parasympathetic activity, are acti-
injury.5 vated up to the level of the lesion. This results in the characteristic
The pathophysiology of ADR is thought to be a result of a dis- symptoms of bradycardia and vasodilation above the lesion.
organized sympathetic response to stimuli below the level of the Stimuli arise from caudal roots below the level of the lesion,
lesion (Fig. 1). Normal regulation of sympathetic output from the with ∼80% of patients being because of bladder distension.4
spinal cord is modulated by input from higher centres. Interrup- Other triggers include bowel distension, acute abdominal path-
tion within the spinal cord results in loss of this higher input. ology, urinary tract infections, skeletal fractures, pressure ulcers,
Spinal circuits below the lesion are established and result in activation of pain fibres, sexual activity, and uterine contractions.
Thromboembolism
The risk of venous thromboembolism in the first 3 months after
an acute SCI is ∼85% if left untreated, necessitating prophylactic
anticoagulation.7 After this period, the risk decreases and
prophylaxis is not routinely required.8 This reduction in risk
from 3 months may be secondary to the effect of lower limb
spasms on muscle pump action along with femoral artery atro-
phy and reductions in venous distensibility. However, in the peri-
operative period, the risk is again increased and standard
thromboprophylaxis is recommended according to local hospital
policy, with low-molecular-weight heparin and antithrombotic
stockings, or mechanical devices as appropriate for the
procedure.
Respiratory system
Respiratory mechanics
Respiratory mechanics are altered after SCI, with the degree of
ventilatory dysfunction dependent on the level and complete-
ness of the lesion. Complete injury renders ventilatory muscles
below the injury completely non-functional. Incomplete lesions
may allow for variable muscle function.
associated with a higher incidence of obesity and accessory mus- arising for musculoskeletal structures and viscera, and neuro-
cle hypertrophy. pathic pain from spinal cord and nerve damage. It is important
to identify painful stimuli and take this into consideration
Ventilatory support when cannulating or positioning patients. It can be a source of
Around a fifth of patients with cervical SCI patients require a discomfort, but also could trigger ADR.
tracheostomy.12 This is commonly necessary for prolonged mech-
anical ventilation resulting from respiratory muscle fatigue, im- Psychological complications
paired secretion clearance, and respiratory complications such Psychological complications of post SCI include depression, sui-
as pneumonia and atelectasis. Occasionally, they are needed for cide, and drug addiction.
airway protection in patients of high cervical lesions involving cra-
nial nerves. Most are uncuffed tubes for use with domiciliary ven-
Gastrointestinal system
tilators. These allow greater tolerance of leaks, compared with
conventional ventilators, facilitating communication. Gastric emptying is delayed in patients, particularly with high-
level injuries. The most common gastrointestinal disturbances
Musculoskeletal system are constipation, distension, abdominal pain, and rectal bleed-
ing. Bowel distension is a potent trigger for ADR. There is a high
Spasticity and contractures incidence of gallstones, with patients at an increased risk of de-
Spasticity occurs as a result of hyper-excitable spinal reflexes veloping advanced biliary complications.
causing exaggeration of the stretch reflex arc. Spasms can be a
cause of severe morbidity and can be provoked by minor stimuli.
Contractures are also common and can complicate optimal surgi- Genitourinary system
cal positioning. The most common oral treatment for spasticity is Commonly there is impaired sensory and motor innervation to
the GABA-B agonist baclofen, with an occasional use of benzodia- the bladder resulting in a neurogenic bladder. Sequelae of this in-
zipines; both of which may cause sedation. Increasingly, intra- clude reduction in bladder capacity, incomplete emptying,
thecal baclofen delivered via indwelling infusion pumps are chronic retention, and frequent urinary tract infections. Urinary
used and vigilance to the position of the diathermy plate must tract infections are the most frequent source of septicaemia in
be paid in these instances. SCI patients, which carries a significant mortality.
Detrusor sphincter dyssynergia can also occur where the
Osteoporosis bladder contracts against a closed sphincter leading to elevated
Decreased bone density is common in CSCI patients with ∼60% of bladder pressures and vesico-ureteral reflux. This can cause
patients having osteoporosis at 15 yr after their injury and 34% renal impairment and nephrolithiasis. Most patients therefore
have had at least one fracture.13 This must be considered in pa- require bladder intervention, either in the form of indwelling ca-
tient handling and positioning. theters, usually suprapubic, or intermittent catheterization.
Neurological system
General. These include peptic ulcer perforations, intestinal ob-
Chronic pain struction, complications of acute cholecystitis, and appendicitis.
Around 65% of CSCI patients have chronic pain. Pain may be both Delay in diagnosis is common resulting in increased morbidity by
nociceptive and neuropathic in nature, with nociceptive pain the time of surgery.
Musculoskeletal. Osteopenia, contractures, spasticity, and falls all Table 1 Common anaesthetic preoperative workup
increase the risk of limb fractures requiring emergency ortho-
paedic procedures. Pressure sores may be the source of sepsis Blood workup
FBC Anaemia and infections are
or osteomyelitis and require intervention.
common
Urea and electrolytes Renal impairment and electrolyte
Elective surgery.Urological. Recurrent urinary tract infections and disturbances
long-term catheterization increase the risk of bladder cancer. Liver function tests May be required if there is chronic
Cystoscopy is a common procedure as is insertion of suprapubic sepsis
catheters and botox injections for the management of neuro- Arterial blood gas If there are concerns regarding
pathic bladders. hypoventilation, or an active chest
infection. A baseline is useful
General. Patients may require a defunctioning colostomy to pre- before operation for patients on
assisted ventilation
vent infection from perineal and sacral pressure sores and
Microbiology
allow healing or for the management of neuropathic bowel and
Routine swabs To identify colonization with
chronic constipation.
nosocomial acquired organisms
Cultures Including urine, blood, and sputum
Spinal surgery. In the acute phase, patients often require reduc- in the presence of a suspected
tion, decompression, and stabilization of fractures. Occasionally, infection
metalwork will need to be revised or removed. It is common for Respiratory
patients with longstanding SCI to develop scoliosis, which re- Vital capacity To provide a baseline, this may
quires correction. indicate the necessity of
perioperative assisted ventilation
Chest radiograph Hypoventilation may be because of
Intrathecal baclofen pumps. Baclofen pumps are used in patients
collapse or active infection
which severe spasticity requiring large doses of anti-spasmodic
requiring attention before
medications precipitating unwanted side-effects. The operation
operation
includes insertion of a lumbar or low thoracic catheter, tunnelled
MRI Patients with prolonged periods of
to the connecting pump that is inserted in the lower abdominal
intubation that have subsequently
wall. been decannulated may be left
with tracheal stenosis. An MRI
Preoperative assessment and investigations may be useful if there is a history
suggesting tracheal stenosis
History and examination—key points (Table 1).Level of and complete- Cardiovascular
ness of the injury. High and incomplete injuries are more likely to Observations Baseline blood pressure and heart
experience ADR. The time since the injury may influence choice rate
of drugs used, such as succinylcholine. Electrocardiogram If there is any evidence of rhythm
disturbances or ischaemic heart
Autonomic dysreflexia. The focus should include identification of disease
Echocardiogram Not routine unless otherwise
susceptible patients, establishing a history of previous episodes
indicated
including known triggers, frequency, and severity. A review of
Musculoskeletal
previous anaesthetic charts will reveal prior anaesthetic techni-
Plain radiographs or X-ray and CT scans of metal work in
ques and any episodes of ADR under anaesthesia. Potential trig-
computerized tomography the spine that may compromise
gers for ADR should be sought and treated before operation
the insertion of regional
including checking for catheter blockages, ensuring bowels anaesthesia should be reviewed
have been emptied and vigilance for skin ulceration.
• ADR in situ post-delivery, because the contracted uterus can still pro-
• Urological problems including sepsis and pyelonephritis voke ADR in susceptible patients. It is important to recognize
• Thromboembolism that these patients still have the potential of developing pre-
• Pressure sores and ulcers eclampsia during their pregnancy and this diagnosis should al-
• Respiratory compromise because of the effects of the gravid ways be considered when hypertension is present.
uterus
• Pre-term delivery
• Higher rate of Caesarean section
Declaration of interest
None declared.
The anaesthetist should be aware when considering regional
block that patients with SCI have a lower blood volume and usu-
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Oswestry
Dublin
The Midland’s Centre for Spinal Injuries 01691 404 655, The Rob-
ert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry SY10 National Medical Rehabilitation Hospital 00 3 531 2854 777, Ro-
7AG. chestown Avenue, Dunlaoghaire, Dublin.