Preventing Autonomic Dysreflexia with the Appropriate Type and Level of Care

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February 9, 2024|Craig H. Lichtblau, M.D., P.A. International Journal of Physical Medicine and Rehabilitation|

Craig H Lichtblau1,2,3*, Scott Raffa4, Kaveh Asadi5, Christopher Warburton6, Gabrielle Meli6, Allyson Gorman7 

1Medical Director, Osseointegration Program, Physical Medicine and Rehabilitation Consultant to the Paley Orthopedic and Spine Institute, West Palm Beach, FL, USA, St. Mary’s Medical Center Consultant to Children’s Medical Services for the State of Florida, District 9; 2Neurosurgeon, Paley Orthopedic and Spine Institute at St. Mary’s Medical Center, West Palm Beach, FL, USA; 3Pediatric Neurosurgeon, Paley Orthopedic and Spine Institute at St. Mary’s Medical Center, West Palm Beach, FL, USA; 4University of Miami Miller School of Medicine, Miami, FL, USA

DESCRIPTION

Autonomic dysreflexia is a potentially lethal syndrome that arises in patients with Spinal Cord Injury (SCI), and involves a sudden, reflexive increase in blood pressure [1]. This blood pressure enhancement occurs when there is an uncoordinated sympathetic response to a noxious stimulus below the level of injury, most often from the bladder [2]. Specifically, urinary tract infections or procedures on the urinary tract, obstructed foley catheters, distended bladder, rectal impaction, skin pressure ulcers, and childbirth, can all lead to autonomic dysreflexia [3-5]. Because the SCI has rendered the body incapable of proper central inhibition in the face of stimulation, there is an outsized outflow that leads to hypertension [6]. When stretch receptors in the carotid sinus and aortic body perceive this heightened pressure, their activation leads to bradycardia and vasodilation through afferent nerve signaling that stimulates the sinoatrial node.

Because of the life-threatening nature of autonomic dysreflexia, and the inability to cure SCI patients from being prone to the syndrome, proper care is critical to ensuring the well-being of the relevant patient population. Here, we review details of autonomic dysreflexia and its complications, as well as the best ways to manage at-risk patients.

Autonomic dysreflexia is common following certain spinal cord injuries

Between 5 and 7 out of 10 SCI patients whose injury occurs above T6 develop autonomic dysreflexia [2]. Though much less common, autonomic dysreflexia can also occur in lower-level SCIs and in non-traumatic SCIs. In addition to the level, the completeness of SCI is relevant for predicting the severity and frequency of episodes of autonomic dysreflexia. Those with complete SCI have a 91% likelihood of experiencing autonomic

dysreflexia, compared to only 27% of those with incomplete

SCI.

Most SCI patients who develop autonomic dysreflexia will develop it within a year post-injury [7]. However, the syndrome normally does not develop until reflexes have recovered, with the earliest reported case being 4 days following the injury.

While patients with autonomic dysreflexia can be asymptomatic, severe headache, excessive sweating, bradycardia, and facial flushing tend to accompany the syndrome [8,9]. Respiratory insufficiency is often an overlooked sign of autonomic dysreflexia [10]. Other symptoms that occur with autonomic dysreflexia include nausea, vomiting, anxiety, visual disturbances, and nasal congestion [2].

Complications from autonomic dysreflexia can be life-threatening

An autonomic dysreflexia episode involves a systolic blood pressure increase of at least 25 mmHg above baseline [2]. When a systolic pressure increase reaches 40 mmHg above baseline or at least 150 mmHg, it is considered a significant episode. There are several complications of autonomic dysreflexia, including seizures, left ventricular dysfunction, pulmonary edema, intracranial hemorrhage, reversible encephalopathy syndrome, and retinal detachment [11,12].

When cerebral vasodilation, which often occurs with autonomic dysreflexia, is combined with dangerously high blood pressure, patients are at significant risk for hemorrhagic stroke. Compared to those without autonomic dysreflexia, those with the syndrome have a 300% to 400% higher chance of suffering a stroke [2].

The heart is also at risk during autonomic dysreflexia, and the higher the level of injury, the more severe the cardiovascular dysfunction. While bradycardia that occurs with autonomic

Correspondence to: Craig H Lichtblau, Medical Director, Osseointegration Program, Physical Medicine and Rehabilitation Consultant to the Paley Orthopedic and Spine Institute at St. Mary’s Medical Center, West Palm Beach, FL, USA, Consultant to Children’s Medical Services for the State of Florida, District 9, E-mail: c.lichtblau@chlmd.com

Received: 16-Dec-2023, Manuscript No. JPMR-23-28507; Editor assigned: 19-Dec-2023, PreQC No. JPMR-23-28507 (PQ); Reviewed: 05-Jan-2024, QC No. JPMR-23-28507; Revised: 15-Jan-2024, Manuscript No. JPMR-23-28507 (R); Published: 23-Jan-2024, DOI: 10.35248/2329-9096.23.11.711

Citation: Lichtblau CH, Raffa S, Assadi K, Warburton C, Meli G, Gorman A (2024) Preventing Autonomic Dysreflexia with the Appropriate Type and Level of Care. Int J Phys Med Rehabil. 11:711.

Copyright: © 2024 Lichtblau CH, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

dysreflexia may be minor, in those with coronary artery disease, autonomic dysreflexia episodes can cause heart attacks.

Treatments for autonomic dysreflexia do not address the underlying pathophysiology

Pharmacological treatments aimed at alleviating autonomic dysreflexia include anti-hypertensive nitrates, adrenergic blockers, and nifedipine, with 10 milligrams (mg) of nifedipine often used as the initial treatment [2,13]. In emergency cases of severe hypertension, nitroglycerine 2% paste is recommended. Botox injections to the bladder are often employed to address autonomic dysreflexia.

Unfortunately, there are several downsides to the currently available treatments for autonomic dysreflexia. In addition to the side effects, which include nausea, vomiting, tachycardia, cardiac arrhythmia, rebound hypotension, flushing, and drowsiness, in many cases, treatment does not reverse the syndrome [2,13]. Further, these pharmacological interventions do not address the underlying cause of sympathetic dysregulation and instead provide only short-term effects in certain organs [14].

While suppressing sympathetic hyperactivity is the aim of several treatment interventions, it is generally agreed that prevention is the best way to address autonomic dysreflexia [15-17].Given that autonomic dysreflexia is commonly caused by urinary bladder distension and recto-sigmoid fecal impaction, care programs that ensure frequent voiding and bowel care are critical [13,17-19]. Proper skin care practices are also essential for the well-being of patients prone to autonomic dysreflexia [20]. Removing the stimulus that is the cause of autonomic dysreflexia as soon as autonomic dysreflexia occurs is necessary before the condition turns into a medical emergency.

Type and level of care are critical for the well-being of those with autonomic dysreflexia

For those prone to autonomic dysreflexia, the syndrome is a constant threat that can occur daily [21]. Further, proper and immediate response is critical in the face of autonomic dysreflexia [22]. It is therefore vital that patients have the right type and level of care for identifying autonomic dysreflexia and administering potentially life-saving interventions. Certain patient populations, including pregnant women, are particularly vulnerable and need specialized attention and monitoring [23].

Medical staff who are not familiar with autonomic dysreflexia often fail to identify it [1]. Further, knowledge of autonomic dysreflexia, including its causes and consequences, is much lower among healthcare professionals with lower levels of training [24,25]. Thus, care from a home health aide is not adequate for optimizing health outcomes for those prone to autonomic dysreflexia.

Successful management of SCI patients at heightened risk for autonomic dysreflexia requires knowledge of guidelines that help in the avoidance of dangerous complications. This management often involves a multidisciplinary approach that

includes specialists across spinal rehabilitation, urology, gastroenterology, and other relevant clinical areas [2,12].

Nurses are often the first healthcare providers to identify the syndrome and are key for monitoring patients with autonomic dysreflexia [2]. As such, nursing-driven protocols for treating the syndrome have been shown to be highly successful and associated with low incidences of adverse events [26]. RN, LVN, or LPN level of care is therefore required to protect the health of those who experience autonomic dysreflexia and to prevent untimely death.

CONCLUSION

Patients prone to autonomic dysreflexia are at a constant risk for life-threatening complications. Their well-being relies on their access to consistent and reliable care from those who are knowledgeable about the syndrome and know how to identify and rapidly intervene when the syndrome occurs. Unfortunately, many healthcare professionals do not have the relevant training to ensure the safety of this patient population. Careful consideration must therefore be taken to develop treatment plans for each patient at risk for autonomic dysreflexia.

REFERENCES

  1. Alwashmi AH. Spinal cord injury and autonomic dysreflexia: A case report on an overlooked complication of spinal cord injury. Cureus. 2022;14(10).
  2. Shahrokhi M, Asuncion RM. Neurologic exam. StatPearls. 2023.
  3. Abdou CA, Wolff EH, Tracey AT, Klausner AP. Metastatic melanoma to the bladder presenting as autonomic dysreflexia in a patient with paraplegia. Urol Case Rep. 2021;39:101820.
  4. McGregor JA, Meeuwsen J. Autonomic hyperreflexia: A mortal danger for spinal cord-damaged women in labor. Am J Obstet Gynecol. 1985;151(3):330-333.
  5. Hall PA, Young JV. Autonomic hyperreflexia in spinal cord injured patients: Trigger mechanism-dressing changes of pressure sores. J Trauma. 1983;23(12):1074-1075.
  6. Erickson RP. Autonomic hyperreflexia: Pathophysiology and medical management. Arch Phys Med Rehabil. 1980;61(10): 431-440.
  7. Daroff RB, Aminoff MJ. Encyclopedia of the neurological sciences. Academic press. 2014.
  8. Lee ES, Joo MC. Prevalence of autonomic dysreflexia in patients with spinal cord injury above T6. Biomed Res Int. 2017.
  9. Henke AM, Billington ZJ, Gater Jr DR. Autonomic dysfunction and management after spinal cord injury: A narrative review. J Pers Med. 2022;12(7):1110.
  10. Andrade MJ, Quintas FL, Silva AM, Cruz P. Is autonomic dysreflexia a cause of respiratory dysfunction after spinal cord injury?. Spinal Cord Ser Cases. 2021;7(1):4.
  11. Wan D, Krassioukov AV. Life-threatening outcomes associated with autonomic dysreflexia: A clinical review. J Spinal Cord Med. 2014;37(1):2-10.
  12. Squair JW, Phillips AA, Harmon M, Krassioukov AV. Emergency management of autonomic dysreflexia with neurologic complications. CMAJ. 2016;188(15):1100-1103.
  1. Rabchevsky AG, Kitzman PH. Latest approaches for the treatment of spasticity and autonomic dysreflexia in chronic spinal cord injury. Neurotherapeutics. 2011;8:274-882.
  2. Sharif H, Hou S. Autonomic dysreflexia: A cardiovascular disorder following spinal cord injury. Neural Regen Res. 2017;12(9):1390.
  3. Blackmer J. Rehabilitation medicine: 1. Autonomic dysreflexia. CMAJ. 2003;169(9):931-935.
  4. Bycroft J, Shergill IS, Choong EA, Arya N, Shah PJ. Autonomic dysreflexia: A medical emergency. Postgrad Med J. 2005;81(954): 232-235.
  5. Balik V, Šulla I. Autonomic dysreflexia following spinal cord injury. Asian J Neurosurg. 2022;17(02):165-172.
  6. Milligan J, Lee J, McMillan C, Klassen H. Autonomic dysreflexia: Recognizing a common serious condition in patients with spinal cord injury. Can Fam Physician. 2012;58(8):831-835.
  7. Krassioukov A, Warburton DE, Teasell R, Eng JJ. A systematic review of the management of autonomic dysreflexia after spinal cord injury. Arch Phys Med Rehabil. 2009;90(4):682-695.
  8. Del Fabro AS, Mejia M, Nemunaitis G. An investigation of the relationship between autonomic dysreflexia and intrathecal baclofen

in patients with spinal cord injury. J Spinal Cord Med. 2018;41(1): 102-105.

  1. Cragg J, Krassioukov A. Autonomic dysreflexia. CMAJ. 2012;184(1):66.
  2. Mizuno H, Honda F, Ikota H, Yoshimoto Y. Autonomic dysreflexia associated with cervical spinal cord gliofibroma: Case report. BMC Neurol. 2021;21:1-7.
  3. Soh SH, Lee G, Joo MC. Autonomic dysreflexia during pregnancy in a woman with spinal cord injury: A case report. J Int Med Res. 2019;47(7):3394-3399.
  4. Tederko P, Ugniewski K, Bobecka-Wesołowska K, Tarnacka B. What do physiotherapists and physiotherapy students know about autonomic dysreflexia?. J Spinal Cord Med. 2021;44(3):418-424.
  5. Strčić N, Markić D. The knowledge about autonomic dysreflexia among nursing and physiotherapy students. J Spinal Cord Med. 2019;42(6):791-796.
  6. Solinsky R, Svircev JN, James JJ, Burns SP, Bunnell AE. A retrospective review of safety using a nursing driven protocol for autonomic dysreflexia in patients with spinal cord injuries. J Spinal Cord Med. 2016;39(6):713-719.