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Diane Newman: Welcome to your UroToday's Bladder Health Center of Excellence. I'm Diane Newman. I'm a nurse practitioner at the University of Pennsylvania and I'm the Center's editor. And I'm really excited because we have a really great speaker. Dr. Todd Linsenmeyer is the director of urology at Kessler Institute for Rehabilitation in New Jersey. He's also professor in the Department of Surgery, Division of Urology, and research professor in the Department of Physical Medicine and Rehabilitation at Rutgers New Jersey School of Medicine. A little tidbit here that I think is really important is he's currently the only practicing physician in the United States who has all these certifications. So really we have a great expert here to talk to us. He's also chairman of the PVA sponsored clinical practice guideline that he's going to talk about that addresses the management of autonomic dysreflexia, which is what I've asked him to present, especially following spinal cord injury. And this guideline talks about the urological management of individuals with spinal cord injury. So welcome.

Todd Linsenmeyer: Well, thank you very much and thank you for that nice introduction and I'm certainly pleased to get to speak about autonomic dysreflexia. And basically autonomic dysreflexia in those with high level spinal cord injuries is the normal sympathetic system, the fight and the flight's response, it's on steroids. And a consumer group and our autonomic dysreflexia panel has defined this as being a sudden, uncontrolled rise in the systolic blood pressure greater than 20 millimeters above a person's normal blood pressure. And this can occur in a spinal cord injury in a person that has an injury that's a T6 and above in response to an uncomfortable or painful stimulus. And one thing that's important to notice is that people with a spinal cord injury have a normal systolic blood pressure that's between 90 and 110. And so basically if you have a spinal cord person with a high level injury, a blood pressure, let's say, of 130 can actually mean there's something wrong and they're having dysreflexia.

So why T6? Well, what happens is the carotid baroreceptors can record and they can detect when the blood pressure's starting to get very high and they send the signals down through the T7 area and then that goes down and it gives feedback to tell the intestinal blood vessels to relax and to not keep contracting, which is the main player in making the blood pressure go up. So as you can see, if you have an injury in T6, these responses can't get back down and the intestinal blood vessels constrict and they keep doing this and everything keeps going higher and higher until you finally get rid of the noxious stimuli. What I'd like to do is actually tell you about one of the patients I've had and told me his experience with dysreflexia. And then toward the end of the presentation, I'd like to actually go over some of the things that could be done differently.

So this was a 21-year-old male with a C5, complete tetraplegia, since 2010, and he had an indwelling catheter and it was being changed by his new home health nurse. And the nurse thought the catheter was in his bladder and the catheter balloon was blown up, but unfortunately it was in his urethra and he developed immediate autonomic dysreflexia and then bleeding at the meatus. The balloon was deflated and the catheter was left in place. 911 was called and he was taken to the ER in a stretcher. Then the on-call urologist was consulted and blood was noted at the meatus and his systolic blood pressure was 170. The urologist put in a new catheter and irrigated his bladder and the blood clots were removed. However, during this process of irrigation, the individual suddenly had a seizure. He was rolled into the radiology department, an abdominal binder was removed, and he had a CT scan performed of his head and his abdomen and a CT scan revealed an acute subarachnoid hemorrhage.

So what I'd like to do is to go over our clinical practice guidelines, and this is the newest edition that's come out. And I'm going to focus on just some of the highlights of this guideline with particular focus to urology. First of all, what and who is a spinal cord consortium. Well, this is actually a group of 23 healthcare professional, payer, and consumer organizations all with the purpose of SCI guideline development. And this guideline process was funded and it's administered by the Paralyzed Veterans of America. Each guideline undergoes a rigorous outside methodology review, panel guideline development, a field review, and this can be up to about 90 reviewers and then a legal review before publication. And these guidelines can take between two and four years, usually it's about two and a half years or so from the start until completion and publication. The consortium currently has 13 professional guidelines and eight consumer guidelines. And this is our panel for the Autonomic Dysreflexia guideline. And as Diane said, myself and Andre Krassioukov were the two co-chairman for this guideline.

So why develop a guideline? Well, autonomic dysreflexia occurs in about 75% of individuals with spinal cord injuries at T6 and above. And because of the rapid onset of dysreflexia and potential severe symptoms, the individuals with this condition are often rushed to the nearest healthcare facility that may be staffed by healthcare professionals who have little or no experience in the treatment of dysreflexia, such as you sort of saw in the above scenario. The treatment of autonomic dysreflexia requires quick and decisive treatment. So the first recommendation is to recognize the signs and symptoms of autonomic dysreflexia, and this includes having a very bad headache. It has piloerection or goosebumps, it can have sweating and chills, and this is above the level of the injury. And most importantly, there's a sudden and very high elevation of the blood pressure. The second recommendation is to be aware that autonomic dysreflexia may appear with minimal or no symptoms, and this could be up to about 40% of individuals and this is despite having a very significant elevation in the blood pressure.

And this is known as silent autonomic dysreflexia. And basically this shows why it's very important to keep monitoring the blood pressure and we usually recommend at least every two to four minutes. So the mainstay and the first thing we talk to everybody about is if the blood pressure's elevated, that you need to immediately set the individual up. And this really does help to lower the blood pressure somewhat. The next thing is to then loosen any clothing or if there are any constrictive devices and a number of individuals with injuries that are high level and low blood pressures will use an abdominal binder. And this is sometimes not noted because it's usually under all the clothing. So the next thing to do is to quickly survey the individual for other triggers beginning with the urinary system. And why the urinary system? It's because the bladder distension is the most common cause of dysreflexia. In fact, this in some studies has been shown that 85% of the time episodes of dysreflexia are due to bladder causes.

So if an indwelling catheter is not in place, the first thing do is to catheterize the individual. But prior to inserting a catheter, it's important to try to instill 2% lidocaine jelly if it's immediately available in the room into the urethra and then you need to wait about four to six minutes if possible for that to really start to work. And the reason this is done is because passing the catheter is another noxious stimuli and this can often trigger even a higher blood pressure. It's also important to instill the lidocaine jelly down the suprapubic tract and wait four to six minutes before actually putting the catheter in. And that's because when the catheter actually touches the bladder it can trigger an involuntary bladder contraction and this can worsen in dysreflexia. And in a study that we had done a while ago, we found that there was a significant statistical difference in those who did and did not have the lidocaine jelly with regards to the degree and even having the onset of dysreflexia with the suprapubic catheter changes.

So if the individual has an indwelling catheter, you want to check along the entire lengths for kinks, folds, constrictions, and the correct placement or overfilling of the leg bag. And just so you know, this overfilled leg bag is I find one of the real common problems. When this is all really filled, there's no more drainage down into the bag and the bladder gets distended and causes dysreflexia. So if the problem's found, you want to correct it immediately. If there are no problems with the tubing, drainage bag, or placement, blood pressure is still elevated, then you want to very gently irrigate the bladder with a small amount about 10 or 15 ccs of fluid such as normal saline at body temperature. And the goal is just to determine if the catheter is blocked, but you want to avoid trying to manually compress or tap on the bladder. This will only make the dysreflexia worse.

And if the catheter is blocked, then you just want to take the catheter out. And if you try to vigorously try to unclog the catheter, what'll happen is you'll usually just push these little pieces of sand and stone back inward to the bladder and also make the dysreflexia worse. So here's another good reason for people, especially in urology field, to know how to treat dysreflexia. Recommendation 16 in the guideline says, "If there is a history of difficulty passing a catheter in a male, consider using a coudé catheter or consult urology." And recommendation 18 says, "If difficulties arise in removing or replacing the catheter, consider initiating pharmacological treatment and consider emergency urology consultation." So urologists may often be called in for a consultation when the person's in the middle of a very acute autonomic dysreflexia crisis. Another thing I just wanted to caution is that if that catheter is encrusted and it is though still draining somewhat to not try to pull out real hard if it doesn't seem to come out.

Because what can happen is that catheter will slide into the bulbous urethra, but then it'll get stuck there. It won't go backwards or forward and get things much worse. So really it's important to be able to, in that situation, if you're concerned about that, to take them to the cysto suite or to the OR where there's some anesthesia that can be used to help control the blood pressure. Again after this has all been done, the person's blood pressure during the drainage and after drainage needs to be monitored. And the reason is because when you drain the bladder, then you immediately remove the trigger cause of dysreflexia. So they may get hypotensive if they've been treated with anti-hypertensive medicines such as lidocaine or nitropaste. And if the blood pressure is elevated or persists above 150 millimeters of mercury, and we as a guideline panel decided 150 was a good number to use as treatment, then you want to consider the rapid onset and short duration of pharmacological treatment prior to looking for other instigating causes.

And in fact, if one of my patients come in and they have a very high blood pressure, I'll actually start some pharmacological treatment. And these are the things that I use during procedures and if somebody presents with severe dysreflexia. The nitropaste is used and usually smallest is half an inch, but you can go up to two inches. Usually I use about an inch and it's placed on the forehead so that it can be applied and it can also be very easily wiped off. It usually takes about four to six minutes to really kick in as does the lidocaine jelly. If a person though has very severe dysreflexia, and fortunately this is rare that I need to use nifedipine, but the way we usually administer that is to have an 18 gauge needle and then puncture the capsule and squeeze some of it sublingual and then have them chew and swallow the capsule after that. So let's revisit the scenario and what I'll do is highlight in blue the things that I think could have been done differently.

First of all, they were taken to the ER on a stretcher. The systolic blood pressure was one 70 millimeters of mercury. The new catheter was put in and irrigated and the blood clots were removed. Well notice all of this was done with the person in a lying down position, so that should have been set up even going over to the ER. Also, the systolic blood pressure was very high, and so putting in some lidocaine jelly into the bladder and into the urethra would've also been very helpful. And probably having some nitropaste, if you were comfortable with that, would also be good to get that blood pressure down, particularly if you're going to be start irrigating and trying to get rid of blood clots. They were then rolled to the radiology department, again, still lying down, and the abdominal binder was removed. So they finally found that binder and took it off, which was keeping that blood pressure up as well. Well, the outcome fortunately was that the subarachnoid hemorrhage did resolve without any neurological sequela.

So just sort of continuing just to sort of finish up, if the acute symptoms of dysreflexia persist, including sustained elevated blood pressure, then suspect fecal impaction or constipation. And that's because this is the second most common cause of dysreflexia. If there are no obvious triggers or if the blood pressure cannot be managed locally, the individual really should be referred to a hospital emergency room for evaluation and management and possible hospital admission. The other very important thing is the spinal cord injury individual's education. And we need to make sure we educate the individual, and family members, and caregivers about the recognition of and management of dysreflexia. We have just recently put out a new consumer guide and this was put together by some of us at the panel and also we had some excellent consumers that gave fantastic ideas.

And one of the things that nice on here is there is a QR code, so they can take this to the ER, the QR code can be scanned, and it'll open up the whole professional guideline. So the goal of course is to have the blood pressure come down and the person doing well. Thank you very much for letting me go over this with everyone. And again, this is a guideline that can be downloaded for free from the PVA Consortium and will go into a lot more detail for people as well.