|Year : 2015 | Volume
| Issue : 3 | Page : 377-381
Epidural fentanyl for the prevention of autonomic dysreflexia in chronic spinal cord injury patients undergoing urological procedures
Dalia A Nasr MD 1, Tarek Osman Elsayed2
1 Department of Anesthesia and Intensive Care Medicine, Ain Shams University, Nasr City, Egypt
2 Department of Urosurgery, Ain Shams University, Nasr City, Egypt
|Date of Submission||15-Oct-2014|
|Date of Acceptance||03-Jan-2015|
|Date of Web Publication||29-Jul-2015|
Dalia A Nasr
Department of Anesthesia and Intensive Care Medicine, Ain Shams University, 6 Tawfikia Buildings, 8th District, Nasr City 113311
Source of Support: None, Conflict of Interest: None
Spinal cord injury (SCI) patients with lesions above T6 are susceptible to develop autonomic dysreflexia (AD) during surgery. The aim of this study was to investigate the efficacy of epidural fentanyl for the prevention of AD in chronic SCI patients undergoing urological procedures.
Patients and methods
Thirty chronic SCI patients scheduled for cystoscopy were randomized to receive epidural anesthesia using 5 ml bupivacaine 0.25% with fentanyl 50 µg in 10 ml saline (group F) or 5 ml bupivacaine 0.25% in 10 ml saline (group C).
There was a significant decrease in the blood pressure and the heart rate 20 min after epidural anesthesia in both groups, with significantly lower systolic and diastolic blood pressures in group F compared with group C; however, the systolic and diastolic blood pressure showed a significant increase, with a decrease in the heart rate, in group C compared with group F during bladder manipulation (25 min). Six patients in group C showed manifestations of autonomic dysreflexia, with an increase in the systolic blood pressure more than 160 mmHg and diastolic blood pressure more than 100 mmHg in three of them.
The addition of fentanyl to epidural bupivacaine succeeded in preventing AD manifestations in chronic SCI patients undergoing cystoscopy.
Keywords: autonomic dysreflexia, epidural fentanyl, spinal cord injury, urological procedures
|How to cite this article:|
Nasr DA, Elsayed TO. Epidural fentanyl for the prevention of autonomic dysreflexia in chronic spinal cord injury patients undergoing urological procedures. Ain-Shams J Anaesthesiol 2015;8:377-81
|How to cite this URL:|
Nasr DA, Elsayed TO. Epidural fentanyl for the prevention of autonomic dysreflexia in chronic spinal cord injury patients undergoing urological procedures. Ain-Shams J Anaesthesiol [serial online] 2015 [cited 2019 Sep 20];8:377-81. Available from: http://www.asja.eg.net/text.asp?2015/8/3/377/161711
| Introduction|| |
Spinal cord injury (SCI) patients with lesions above T6 are susceptible to develop autonomic dysreflexia (AD) during urological procedures as a result of exaggerated sympathetic excitation  . AD occurs more often in the chronic stage of SCI: 27% of incomplete tetraplegic individuals compared with 91% of tetraplegic individuals with complete lesions  .
The reflexic response to cutaneous, visceral (bladder), and proprioceptive stimuli are to some extent attenuated by descending, inhibitory impulses. However, in patients with SCI, these impulses may be curtailed, leading to uninhibited spinal cord reflexes and consequent vascular instability. Initially, a substantial increase in blood pressure (BP) above the level of the lesion, with reflex bradycardia, vasodilation, and flushing occur. These patients may suddenly develop headache, sweating, and nasal congestion. During an episode of AD, a significant increase in the visceral sympathetic activity with coronary artery constriction can result in myocardial ischemia, even in the absence of coronary artery disease  .
The development of intraoperative AD and hypertension can be prevented either by general anesthesia, which blunts autonomic reflexes, or by regional anesthesia (spinal or epidural), which blocks afferent and autonomic efferent neural impulses , .
The aim of this study was to investigate the efficacy of epidural fentanyl in the prevention of AD in chronic SCI patients undergoing urological procedures.
| Patients and methods|| |
This study was conducted during the period from February 2011 to December 2013. After approval of the local departmental ethics committee of the Department of Anesthesiology, Intensive Care, and Pain Management, Faculty of Medicine, Ain Shams University (Cairo, Egypt), and an informed written consent from the patients' next of kin was obtained, 30 male patients classified as American Society of Anesthesiologists (ASA) physical status II-III, 35-55 years old, with chronic, clinically complete cord injuries scheduled for cystoscopy, were enrolled in this randomized, double-blind study. Exclusion criteria included patients with clinically significant cardiovascular, pulmonary, or metabolic diseases, patients who took medications that would influence autonomic or cardiovascular responses to the surgery, or patients who took opioid-containing medications on a long-term basis.
On arrival at the operating room, regular monitors were applied; vital signs were recorded including ECG, heart rate, noninvasive BP, and pulse oximetry (SpO 2 ). A good venous access was secured with an 18-G cannula and patients were prehydrated with 10 ml/kg of lactated Ringer's solution.
Lumbar epidural anesthesia was induced using an 18-G Tuohy needle in the L3-L4 interspace, and an epidural catheter was secured 3-5 cm into the epidural space. Patients were randomly assigned to one of the two groups using a computer-generated random number list. The list was created using the GraphPad StatMate (version 1.01i; GraphPad Software Inc., San Diego, California, USA) software and was accessible to anesthesiologists undergoing epidural anesthesia through the computer database.
The fentanyl group received 5 ml bupivacaine 0.25% with fentanyl 50 µg in 10 ml saline (group F) and the control group received 5ml bupivacaine 0.25% in 10 ml saline (group C). To maintain blindness, all drugs were prepared by an anesthetic resident, who was not involved in any part of the study.
Patients were positioned in the lithotomy position after 20 min of injection in both groups. Vital signs were recorded every 5 min throughout the procedure.
Cystoscopy was performed by a urologist who was also blinded to the epidural medications. The cystoscopy was performed for diagnostic purposes or for treatment purposes such as stone retrieval, sphincterotomy, or botox injection. There was no difference in the indications for cystoscopy between both groups.
Any complaints of patients, such as nasal obstruction, facial tingling, headache, or blurred visions, were recorded. Signs of hyperreflexia such as sweating and vasodilatation in the upper half of the body were observed and recorded. If any occurred, the operation was stopped, the patient's head was elevated and legs were lowered, the BP was monitored every 2-5 min, and any pressing over the bladder was avoided.
If the systolic blood pressure (SBP) became 160 mmHg or more or the diastolic blood pressure (DBP) 100 mmHg or more, sublingual nifedipine 10 mg was given, and the operation was stopped till the BP became normotensive again.
The attending anesthesiologist who observed the patients and collected the data was blinded to the study group assignment.
The sample size was estimated using the G*Power software (version 3.1.0; Institut für Experimentelle Psychologie, Heinrich Heine Universität, Düsseldorf, Germany). Considering a two-tailed α-error of 0.05 and a β-error of 0.2, it was estimated that a minimum of 12 patients had to be included in each study group to detect a 30% difference in the incidence of AD manifestations between the two groups. The statistical analysis was performed using a standard SPSS software package (SPSS Inc., Chicago, Illinois, USA). Data are presented as mean values ± SD, percentages, and numbers. One-way analysis of variance was used to analyze continuous variables. Student's t-test was used to analyze parametric data and discrete (categorical) variables were analyzed using the χ2 test. A P-value of less than 0.05 was regarded as statistically significant.
| Results|| |
Thirty-five patients were eligible for the study: four patients were excluded, two did not meet the inclusion criteria, and two refused to participate. Hence, 31 patients were randomized: 16 in group F (where the surgery was canceled in one patient) and 15 in group C. Fifteen patients in each group completed the study [Figure 1].
[Table 1] shows the demographic characteristics of both study groups. There were no statistically significant differences between the two groups regarding patients' age, weight, ASA physical status, and duration of operation.
There were no significant differences in the mean values of baseline vital signs (BP and heart rate). There was a significant decrease in the BP and the heart rate 20 min after epidural anesthesia in both groups, with significantly lower SBP and DBPs in group F compared with group C; the SBP and DBP showed a significant increase in group C compared with group F during bladder manipulation (25 min); it began to decrease gradually at the subsequent readings, but was still higher than in group F [Table 2] and [Table 3].
Six patients in group C showed manifestations of autonomic hyperreflexia, with an increase in the SBP more than 160 mmHg and DBP more than 100 mmHg in three of them; nifedipine 10 mg sublingual was given and their BP decreased gradually to within accepted values. Data from these patients are shown in [Table 4].
|Table 4: Data of patients in the control group with manifestations suggestive of autonomic dysreflexia|
Click here to view
Two patients in group F complained of headache, which was not accompanied by either an increase in the BP or any cutaneous manifestations suggestive of AD.
No change in oxygen saturation occurred in both groups.
| Discussion|| |
The current study showed that the administration of epidural fentanyl in chronic SCI patients undergoing cystoscopy was associated with a significant reduction in the incidence of manifestations of AD compared with those who received epidural bupivacaine alone.
The choice of the type of anesthesia for SCI patients is controversial. It was shown that during general anesthesia, the concentration of an inhaled anesthetic required to block AD is high enough to cause severe hypotension in these patients  ; also, subarachnoid block may cause a precipitous decrease in the arterial BP  .
The use of epidural anesthesia in SCI patients has been described previously in isolated case reports for the prevention of AD during labor , . However; evidence from randomized controlled trials in other procedures are sparse. Epidural anesthesia in SCI patients was reported as being less satisfactory either due to a failure to block sacral segments or due to missed segments resulting from distortion of the epidural space  .
The use of narcotics in epidural anesthesia has been proven to be satisfactory. A study on a quadriplegic parturient postulated that epidural meperidine produced selective blockade of spinal opiate receptors, and hence blocked nociceptive reflexes below the level of the cord transection, thus preventing AD , . Also, Ginosar et al.  demonstrated that when coadministered with local anesthetics, epidural fentanyl has a marked local anesthetic-sparing effect when compared with an equal dose of fentanyl infused intravenously. They suggested that infused epidural fentanyl elicits analgesia by a predominantly spinal mechanism in the presence of local anesthetics  . In the current study, patients who received epidural fentanyl did not complain of any symptoms of AD, and no signs were observed compared with those who received bupivacaine alone, proving the efficacy of combining epidural narcotics with local anesthetics.
Also, we observed that the hemodynamics of the patients who received epidural fentanyl were stable during the procedure, especially during bladder manipulation. In the control group, although the BP was not highly elevated as observed in previous case reports (SBP ≥200 mmHg or DBP ≥120 mmHg), this was considered as a dysreflexic episode  . It was found that the usual resting arterial BP in individuals with cervical and high thoracic SCI is ~15-20 mmHg lower than in able-bodied individuals  . Hence, an acute elevation of BP to normal or slightly elevated ranges could indicate AD in this population  .
In contrast, Abouleish et al.  reported a case of quadriplegic parturient where epidural fentanyl failed to control AD. Carrie et al.  found that epidural fentanyl, up to a dose of 200 μg, was effective only in controlling early first-stage labor pains, whereas failed in advanced first and second stages  . Two reasons may explain this difference from our results. First, in these two cases, epidural fentanyl was used alone without the addition of bupivacaine; it has been proved that the addition of bupivacaine to narcotics suppressed AD completely due to its local anesthetic effect  . Second, both cases were for parturients at different stages of labor with cervical dilatation, wherein there was incomplete suppression by fentanyl to visceral noxious stimuli.
We found that epidural anesthesia allowed patients to be awake to complain of early symptoms of AD such as nasal obstruction, facial tingling, headache, or blurred vision, which might be observed before the increase in the BP; it also allowed us to use sublingual nifedipine, which was proved to be very effective in controlling hypertension  . Lastly, the presence of the epidural catheter allowed us to begin with a low dose of narcotics and local anesthetics, which could be increased if the patient needed.
There were some limitations in this study. First, it was impossible to determine the sensory level of the block using a pinprick or an alcohol swab in our patients, and so we depended on the experience of the anesthetist performing the block. Second, our patients' cause of quadriplegia was injury to the cervical spine; we did not include patients with kyphoscoliosis, previous spinal surgery, inability to flex the spine due to spasms, and bony deformities as all represent technical difficulties in performing epidural anesthesia. Third, because no sufficient data exist on the use of epidural fentanyl for the prevention of AD in SCI patients undergoing surgical procedures, any dosage recommendation would be arbitrary. Taking into consideration the dosages cited by other authors for the prevention of AD (75 μg of fentanyl or 100 μg) , , the current study used an average dose that might be effective and at the same time we avoided higher doses that might cause respiratory depression. Fourth, we did not have the data on the incidence of AD in these patients before cystoscopy such as AD that might have been occurring on catheterization or crede voiding or fecal impaction. Such data, if available, might help to select patients who will benefit the most from fentanyl epidural anesthesia.
In conclusion, the addition of fentanyl to epidural bupivacaine succeeded in preventing AD manifestations in chronic SCI patients undergoing cystoscopy.
| Acknowledgements|| |
Conflicts of interest
| References|| |
Cormier CM, Mukhida K, Walker G, Marsh DR. Development of autonomic dysreflexia after spinal cord injury is associated with a lack of serotonergic axons in the intermediolateral cell column. J Neurotrauma 2010; 27:1805-18.
Curt A, Nitsche B, Rodic B, Schurch B, Dietz V. Assessment of autonomic dysreflexia in patients with spinal cord injury. J Neurol Neurosurg Psychiatry 1997; 62:473-7.
Ho CP, Krassioukov AV. Autonomic dysreflexia and myocardial ischemia. Spinal Cord 2010; 48:714-5.
Stowe DF, Bernstein JS, Madsen KE, McDonald DJ, Ebert TJ. Autonomic hyperreflexia in spinal cord injured patients during extracorporeal shock wave lithotripsy. Anesth Analg 1989; 68:788-91.
Hambly PR, Martin B. Anaesthesia for chronic spinal cord lesions. Anaesthesia 1998; 53:273-89.
Yoo KY, Jeong CW, Kim SJ, Chung ST, Bae HB, Oh KJ, Lee J. Sevoflurane concentrations required to block autonomic hyperreflexia during transurethral litholapaxy in patients with complete spinal cord injury. Anesthesiology 2008; 108:858-63.
Schowald G, Fish KJ, Perkash I. Cardiovascular complications during anesthesia in chromic spinal cord injured patients. Anesthesiology 1981; 55:550-558.
Owen MD, Stiles MM, Opper SE, McNitt JD, Fibuch EE. Autonomic hyperreflexia in a pregnant paraplegic patient. Case report. Reg Anesth 1994; 19:415-7.
Gaffud MP, Bansal P, Lawton C, Velasquez N, Watson WA. Surgical analgesia for cesarean delivery with epidural bupivacaine and fentanyl. Anesthesiology 1986; 65:331-4.
Kanonidou AE. Anaesthesia for chronic spinal cord lesions. Hippokratia 2006; 10:28-31.
Baraka A. Epidural meperidine for control of autonomic hyperreflexia in a paraplegic parturient. Anesthesiology 1985; 62:688-90.
Vaidyanathan S, Soni B, Selmi F, Singh G, Esanu C, Hughes P, et al.
Are urological procedures in tetraplegic patients safely performed without anesthesia? A report of three cases. Patient Saf Surg 2012; 6:3.
Ginosar Y, Columb MO, Cohen SE, Mirikatani E, Tingle MS, Ratner EF, et al
. The site of action of epidural fentanyl infusions in the presence of local anesthetics: a minimum local analgesic concentration infusion study in nulliparous labor. Anesth Analg 2003; 97:1439-45.
Claydon VE, Elliott SL, Sheel AW, Krassioukov A. Cardiovascular responses to vibrostimulation for sperm retrieval in men with spinal cord injury. J Spinal Cord Med 2006; 29:207-16.
Krassioukov A, Warburton D, Teasell R, Eng J. A systematic review of the management of autonomic dysreflexia following spinal cord injury. Arch Phys Med Rehabil 2009; 90:682-695.
Abouleish EI, Hanley ES, Palmer SM. Can epidural fentanyl control autonomic hyperreflexia in a quadriplegic parturient? Anesth Analg 1989; 68:523-6.
Carrie LES, O'Sullivan GM, Seegobin ER. Epidural fentanyl in labour. Anaesthesia 1981; 36:965-969.
[Table 1], [Table 2], [Table 3], [Table 4]