ΡΑΠΙΔΗ AD, 2013, 12ο Β'ΦΙΑπ

12 Ετη σιο Συνε δριοΑΠΟΚΑΤΑΣΤΑΣΗ ΣΕ ΤΕΤΡΑΠΛΗΓΙΚΟΥΣ ΑΣΘΕΝΕΙΣ Ο

ΡΟΛΟΣ ΤΗΣ ΥΨΗΛΗΣ ΤΕΧΝΟΛΟΓΙΑΣ ΣΤΗΝ ΘΕΡΑΠΕΙΑ ΚΑΙ ΕΠΑΝΕΝΤΑΞΗ

Β Κλινικη ΦΙΑπ, ΕΚΑ σε συνεργασια με την Ιατρικη Εταιρεια Αθηνω ν

4 και 5 Οκτωβριου 2013, Αμφιθεατρο, Εθνικο Κεντρο Αποκατα στασης

Κατευθυντηριες οδηγιες στην προ ληψη και θεραπεια της δυσρηφλε ξιας

Τρίτη, 01 Οκτωβρίου 2013

ΑΥΤΟΝΟΜΗ ΔΥΣΑΝΤΑΝΑΚΛΑΣΤΙΚΟΤΗΤΑ

• παθοφυσιολογία: σύντομη αναφορά

• πότε τίθεται η διάγνωση της αυτόνομης δυσαντανακλαστικότητας

• αντιμετώπιση - κατευθυντήριες οδηγίες


νευρογενές shock

νωτιαίο shock

αυτόνομη δυσαντανακλαστικότητα

βλάβες >Θ6

ΟΞΕΙΑ ΦΑΣΗ ΧΡΟΝΙΑ ΦΑΣΗ

Silver JR. Early autonomic dysreflexia. Spinal Cord. 2000; 38(4):229–33Krassioukov AV, Furlan JC, Fehlings MG. Autonomic dysreflexia in acute spinal cord injury: An under-recognized clinical entity. J Neurotrauma. 2003;20(8):707–16.


Αυτόνομη δυσαντανακλαστικότητα

•μετά την έξοδο από τη φάση του νωτιαίου shock

•με την επανεμφάνιση των αντανακλαστικών κάτωθεν της βλάβης

•στο 50-90% των ασθενών με βλάβη πάνω από την σπλάχνική έξοδο του συμπαθητικού (>Θ6)

Corbett et al.,1975; Lindan et al.,1980; Mathias and Frankel,1993; Lee et al.,1995; Giannantoni et al.,1998;Vaidyanathan et al., 1998; Karlsson, 1999; Krassioukov et al., 2003

• παροξυσμική υπέρταση (paroxysmal hypertension – Thompson and Witham, 1948)

• παροξυσμική νευρογενής υπέρταση (paroxysmal neurogenic hypertension - Mathias et al.,1976)

• συμπαθητική υπερρεφλέξια (sympathetic hyperreflexia - Young, 1993)

• σπαστικότητα αυτόνομου (autonomic spasticity - McGuire and Kumar, 1986)


Δυνητικά επώδυνα ή μη, ερεθίσματα κάτωθεν της βλάβης

• διεγείρουν συμπαθητικούς νευρώνες στους διαμεσοπλάγιους θωρακο-οσφυϊκούς πυρήνες

• ο υπερνωτιαίος ανασταλτικός έλεγχος δεν υπάρχει κάτω από την βλάβη

• υπερευαισθησία αδρενεργικών υποδοχέων κάτωθεν της βλάβης (;)

• ανεξέλεγκτη απάντηση του συμπαθητικού συστήματος με απελευθέρωση νορεπινεφρίνης, ντοπαμίνης και β-υδροξυ-ντοπαμίνης στην κυκλοφορία

• η απελευθέρωση αυτών των ουσιών προκαλεί αγγειοσύσπαση στο αρτηριακό δίκτυο που με τη σειρά της προκαλεί αιφνίδια αύξηση στην αρτηριακή πίεση


παθοφυσιολογία

The great Windmill Street School of Anatomy. Spinal Cord (2011) 49, 323

• Bladder distention• Urinary tract infection• Cystoscopy• Urodynamics• Detrusor-sphincter dyssynergia[5] • Epididymitis or scrotal compression• Bowel distention• Bowel impaction• Gallstones• Gastric ulcers or gastritis• Invasive testing• Hemorrhoids• Gastrocolic irritation• Appendicitis or other abdominal

pathology trauma• Menstruation• Pregnancy - Especially labor and delivery• Vaginitis• Sexual intercourse• Ejaculation• Deep vein thrombosis• Pulmonary emboli• Pressure ulcers• Ingrown toenail• Burns or sunburn• Blisters• Insect bites• Contact with hard or sharp objects• Temperature fluctuations• Constrictive clothing, shoes, or

appliances• Heterotopic bone• Fractures or other trauma• Surgical or diagnostic procedures• Pain


οξεία αύξηση ΑΠ συστολικής και διαστολικής (αύξηση >20mmHg) πάνω από την βασική πίεση αναφοράς (συνήθως για υψηλές πάρα και τετραπληγίες 90-110mmHg)

για εφήβους και παιδιά μία αύξηση της τάξης των 15mm Hg αποτελεί ένδειξη επεισοδίου αυτόνομης δυσρηφλέξιας

αυτόνομη δυσαντανακλαστικότηταπότε τίθεται η διάγνωση




“silent”

• Η κλινική εκδήλωση του συνδρόμου δεν είναι αντίδραση τύπου “όλον ή ουδέν”

• συμπτώματα μπορεί να είναι πολύ ήπια – πολύ έντονα

• να απουσιάζουν (ανεξάρτητα από μία πολύ μεγάλη αύξηση της ΑΠ): silent autonomic dysreflexia





105

KRASSIOUKOV et al. Assessment of autonomic dysfunction following SCI

deep tendon reflexes had occurred, while still other groupsdefined the end of spinal shock as ~2 months postinjurywhen recovery of the bladder reflex had occurred. For fur-ther details, we refer readers to the recent work of Ditunnoand colleagues [16].

CARDIAC DYSRHYTHMIAS

Autonomic cardiovascular regulation is compro-mised following SCI, the degree to which relates to thelevel and completeness of the spinal cord lesion [13,17–18]. In persons with injuries above the sixth thoracic (T)

vertebra, reductions in sympathetic cardiovascular con-trol result in hypotension and bradycardia [19–20]. Theseabnormalities may directly reflect disruption of the sym-pathetic circuits within the upper thoracic segments (T1–T5). However, cardiac efferent parasympathetic control,which arises from the brain stem, remains intact after SCIand may also contribute to the bradycardia observed inthose with tetraplegia [21–22].

Bradycardia and cardiac arrest are known complica-tions associated with the acute phase following SCI;these cardiac abnormalities are usually temporary [22–23]. In the acute phase of SCI, stimuli to the trachea, suchas suctioning, commonly induce bradycardia. Normally,

Condition Definition Yes DegreeNeurogenic Shock Commonly occurring condition following SCI associated with failure of

sympathetic nervous system that results in loss of vascular tone in part of body deprived from autonomic control. Operational definition: SBP <90 mmHg in supine posture not result of low intravascular volume (blood loss, dehydration).

Bradycardia Deviations from normal HR.Operational definition: Decrease in HR to <60 bpm. Severity: Mild, no symptoms, SPB >90 mmHg; Moderate, requires intervention to increase HR or maintain adequate BP; Severe, asystole.

Orthostatic Hypotension Operational definition: Sustained decrease in BP >20 mmHg systolic or >10 mmHg diastolic occurring within 3 min when individual moves from supine to upright posture.Severity: Symptomatic (dizziness, headache, fatigue) or asymptomatic.

Autonomic Dysreflexia Operational definition: Constellation of signs/symptoms in SCI above T5–T6 in response to noxious or nonnoxious stimuli below injury level, including increase in BP >20 mmHg above baseline, and may include one or more of following: headache, flushing and sweating above lesion level, vasoconstriction below lesion level, or dysrhythmias. May or may not be symptomatic and can occur at any time following SCI.Severity: Mild/partial, BP increase <40 mmHg; Moderate, SBP rise >40 mmHg, but SBP <180 mmHg; Severe, SBP >180 mmHg.Associated symptoms: piloerection, stuffy nose, other.

Temperature Dysregulation Elevation or decrease of body temperature without signs of infection. May result from exposure to environmental temperature change.

Sweating DisturbancesHyperhidrosis

Hypohidrosis

Nonphysiological sweating over portion of body in response to noxious/nonnoxious stimuli, positioning, etc. Lack of sweating in denervated areas in response to rise in temperature.

Figure.Comprehensive set of definitions of general autonomic nervous system dysfunction following spinal cord injury that should be assessed byclinicians. (Clinicians check Yes if present and indicate Degree.) BP = blood pressure, bpm = beats per minute, HR = heart rate, SBP = systolicblood pressure, SCI = spinal cord injury, T = thoracic.

Andrei V. Krassioukov,et al. J of Rehabilitation Research & Development, Vol 44 (1), 2007

Report of the joint committee of ASIA and the ISCoS concerning the development of assessment criteria for general autonomic function testing

following spinal cord injury (SCI).


Σημεία:

• βραδυκαρδία (πιθανόν μικρού βαθμού ώστε ο καρδιακός ρυθμός να παραμένει εντός φυσιολογικών ορίων όχι<60).

• ταχυκαρδία

• αρρυθμία (κολπική μαρμαρυγή , πρώ ιμες κο ιλ ιακές συστολές , δ ι α τ α ρ α χ έ ς κ ο λ π ο κ ο ι λ ι α κ ή ς αγωγιμότητας)

σημεία-συμπτώματα



Συμπτώματα:

• έντονη κεφαλαλγία

• Θάμβος όρασης

• Εμφάνιση κηλίδων στα οπτικά πεδία

• Ρινική συμφόρηση

• Ανησυχία, άγχος

• πάνω από τη βλάβη: εκσεσημασμένη εφίδρωση (προσώπου, αυχένα, ώμων), flushing και τριχοανόθρωση

• κάτω από τη βλάβη: αγγειοσύσπαση-ωχρότητα

σημεία-συμπτώματα



• 91% ατόμων με πλήρη τετραπληγία θα παρουσιάσουν αυτόνομη δυσρηφλέξια

• motor-complete SCI (ASIA A or ASIA B) είχαν σε αυξημένο % αυτόνομη δυσρηφλέξια από την αρχική νοσηλεία τους (1-6μήνες μετά βλάβη)

• μόνο 27% ατόμων με ατελή τετραπληγία θα παρουσιάσουν αυτόνομη δυσρηφλέξια

• άτομα με ατελή κινητική τετραπληγία ή υψηλή παραπληγία (ASIA C,D) είναι πιθανό να παρουσιάσουν αυτόνομη δυσρηφλέξια πιο μακροπρόθεσμα, μετά την αρχική τους νοσηλεία

επιδημιολογικά στοιχεία



Εκσεσημασμένες και παρατεταμένες εκδηλώσεις αυτόνομης δυσαντανακλαστικότητα που τείνουν να επιδεινώνονται παρά την άρση του παράγοντα που την προκάλεσε.

Κακοήθης αυτόνομη δυσαντανακλαστικότηταMalignant autonomic dysreflexia

Ο μηχανισμός (;)

συνεχής υπερδ ι έγερση κυκλωμάτων κάτω από τη βλάβη που δεν ηρεμούν ούτε και μετά την παύση του εκλυτικού παράγοντα

• σε άνδρες

• χρόνια φάση

• ενίοτε πολλά έτη μετα την κάκωση

• μετά πρόκληση εκσπερμάτισης

• συμπτώματα που επιμένουν περίπου 30min και επαναλαμβάνονται πολλές φορές τη μέρα σχετιζόμενα με την πλήρωση της κύστεως, για αρκετές μέρες/βδομάδες

τ α α ν τ α ν α κ λ α σ τ ι κ ά προώθησης του σπέρματος απα ιτούν (μακροχρόν ια πλαστικότητα) χρόνο για να επαναδραστηριοποιηθούν μετά τη βλάβη ΝΜ

S Elliott, and A Krassioukov, Spinal Cord (2006) 44, 386–392


2009, Διεθνή κριτήρια εκτίμησης της λειτουργίας του ΑΝΣ και σωματικού μετά ΚΝΜ

ΠΛΗΡΗΣ - ΑΤΕΛΗΣ ΒΛΑΒΗσωματο-κινητικά (somatomotoric)σωματο-αισθητικά (somatosensoric)σπλάχνο-κινητικά (visceromotoric)σπλαχνο-αισθητικά (viscerosensoric)

Appendix

Autonomic Standard Assesment Form

International standards to document autonomic functionMS Alexander et al

43

Spinal Cord

Comments:

(scoring on reverse side)

STANDARD NEUROLOGICAL CLASSIFICATION OF SPINAL CORD INJURY

REV 03/06

Patient Name ____________________________________

Examiner Name __________________________________ Date/Time of Exam___________________

(distal phalanx of middle finger)(little finger)

REVIEW

International standards to document remaining autonomicfunction after spinal cord injury

MS Alexander1, F Biering-Sorensen2, D Bodner3, NL Brackett4, D Cardenas4, S Charlifue5, G Creasey6, V Dietz7,J Ditunno8, W Donovan11, SL Elliott9, I Estores10, DE Graves11, B Green12, A Gousse4, AB Jackson1,M Kennelly13, A-K Karlsson14, A Krassioukov9, K Krogh15, T Linsenmeyer16, R Marino8, CJ Mathias17, I Perkash6,AW Sheel9, G Shilero18, B Schurch7, J Sonksen19, S Stiens20, J Wecht18, LAWuermser21 and J-J Wyndaele22

1University of Alabama, Birmingham, AL, USA; 2Rigshospitalet and University of Copenhagen, Copenhagen, Denmark; 3CaseWestern Reserve University, Cleveland, OH, USA; 4University of Miami, Miami, FL, USA; 5Craig Hospital, Englewood, CO, USA;6Stanford University, Palo Alto, CA, USA; 7University Hospital Balgrist, Zurich, Switzerland; 8Thomas Jefferson University,Philadelphia, PA, USA; 9International Collaboration On Repair Discoveries (ICORD), University of British Columbia and VancouverCoastal Health, Vancouver, British Columbia, Canada; 10James A Haley VA Hospital, Tampa, FL, USA; 11Baylor College of Medicine,Houston, TX, USA; 12Shepherd Center, Atlanta, GA, USA; 13McKay Urology, Carolinas Healthcare, Charlotte, NC, USA;14Sahlgrenska University Hospital, Gothenburg, Sweden; 15Aarhus University Hospital, Aarhus, Denmark; 16Kessler Institute forRehabilitation, West Orange, NJ, USA; 17Imperial College, St Mary’s Hospital, London, UK; 18James J Peters Veterans Affairs MedicalCenter, Bronx, NY, USA; 19Herlev Hospital, University of Copenhagen, Copenhagen, Denmark; 20Veterans Affairs Puget Sound HealthCare, Seattle, WA, USA; 21Mayo Clinic, Rochester, MS, USA and 22University Hospital Antwerp, University Antwerp, Antwerp, Belgium

Study design: Experts opinions consensus.Objective: To develop a common strategy to document remaining autonomic neurologic functionfollowing spinal cord injury (SCI).Background and Rationale: The impact of a specific SCI on a person’s neurologic function isgenerally described through use of the International Standards for the Neurological Classification of SCI.These standards document the remaining motor and sensory function that a person may have;however, they do not provide information about the status of a person’s autonomic function.Methods: Based on this deficiency, the American Spinal Injury Association (ASIA) and theInternational Spinal Cord Society (ISCoS) commissioned a group of international experts to developa common strategy to document the remaining autonomic neurologic function.Results: Four subgroups were commissioned: bladder, bowel, sexual function and general autonomicfunction. On-line communication was followed by numerous face to face meetings. The informationwas then presented in a summary format at a course on Measurement in Spinal Cord Injury, held onJune 24, 2006. Subsequent to this it was revised online by the committee members, posted on thewebsites of both ASIA and ISCoS for comment and re-revised through webcasts. Topics include anoverview of autonomic anatomy, classification of cardiovascular, respiratory, sudomotor andthermoregulatory function, bladder, bowel and sexual function.Conclusion: This document describes a new system to document the impact of SCI on autonomicfunction. Based upon current knowledge of the neuroanatomy of autonomic function this paperprovides a framework with which to communicate the effects of specific spinal cord injuries oncardiovascular, broncho-pulmonary, sudomotor, bladder, bowel and sexual function.Spinal Cord (2009) 47, 36–43; doi:10.1038/sc.2008.121; published online 28 October 2008

Keywords: autonomic nervous system; spinal cord injury; human; international standards

Introduction

Currently, the International Standards for the NeurologicalClassification of Spinal Cord Injury (ISNCSCI) are used to

document impairments of motor and sensory function afterspinal cord injury (SCI). These standards are now in the sixthedition. A major revision occurred in 1992 when the firstinternationally accepted standards were published.1 Changesincluded a revised definition of complete and incompleteinjuries, the modification of the Frankel scale to the ASIAImpairment scale, and the addition of sensory scores.Subsequently, a teaching package was developed consisting

Received 19 June 2008; revised 29 August 2008; accepted 31 August 2008;published online 28 October 2008

Correspondence: Dr A Krassioukov, ICORD/Department of Medicine, Uni-versity of British Columbia, 6270 University Blvd, Vancouver, British Columbia,Canada V6T 1Z4.E-mail: [email protected]

Spinal Cord (2009) 47, 36–43& 2009 International Spinal Cord Society All rights reserved 1362-4393/09 $32.00

www.nature.com/sc


ΑΝΤΙΜΕΤΩΠΙΣΗΚΑΤΕΥΘΥΝΤΗΡΙΕΣ ΟΔΗΓΙΕΣ

• ΑΝΤΙΜΕΤΩΠΙΣΗ ΟΞΕΟΣ ΕΠΕΙΣΟΔΙΟΥ ΑΔ

• ΠΡΟΛΗΨΗ ΕΜΦΑΝΙΣΗΣ ΕΠΕΙΣΟΔΙΩΝ ΑΔ


Chronic spinal cord injury: management of patients in acute hospital settings 3

Fig 1. Management of patients with autonomic dysreflexia (AD).

For patients with catheter:• empty leg bag and note volume• check tubing not blocked/kinked

• if catheter blocked remove and re-catheterise using lubricant containing lidocaine

For patients without catheter:• if bladder distended and patient unable

to pass urine insert catheter using lubricant containing lidocaine

If bladder distension excluded – gently examine per rectumFor faecal mass in rectum:

• gently insert gloved finger covered in lidocaine jelly into rectum and remove faecal mass

If blood pressure remains high, then an IV hypotensive may be required: • hydralazine 20 mg iv slowly or

• diazoxide 20 mg bolus. Continue to search for cause and monitor blood pressure.

May require management on high dependency unit if problem persists.Contact a spinal cord injury centre for further advice (see Appendix 4).

If symptoms persist or cause is unknown Give nifedipine or glyceryl trintrate (GTN). In adults, place sublingually: • the contents of a 10 mg sublingual nifedipine capsule or

• 1–2 GTN tablets. Repeat dose can be given after 20 minutes, if symptoms persist.

cord lesion and are still compatible with effectivetissue perfusion. Hypotension from other causesneeds to be distinguished carefully from this picture.Overzealous fluid resuscitation or transfusion cancause pulmonary oedema and increasedmorbidity/mortality. It is helpful to ascertainindividuals' normal resting vital signs beforeplanning intervention.

Individuals with SCI at or above T6 level are at riskof autonomic dysreflexia (AD) – an excessiveautonomic response to stimuli below the level of theSCI, such as a blocked catheter or faecal impaction.This is an acute and life-threatening condition whichall physicians should be aware of. Typical features areshown in Box 1 (p 2), and a suggested pathway formanagement is given in Fig 1.

Sit the patient up – avoid lying down

Check blood pressure • Confirm diagnosis (blood pressure greater than 200/100 or 20–40 mmHg higher

than normal)

Symptoms or signs of AD(eg pounding headache, flushing, sweating or

blotching skin above injury level; pale, cold,

goosebumps below)

CONCISE GUIDANCE TO GOOD PRACTICEA series of evidence-based guidelines for clinical management

NUMBER 9

Chronic spinal cord injury: management of patients in acute hospital settings

NATIONAL GUIDELINES

February 2008 BASCIS


ΚΑΡΤΑ ΑΔ

• Δυστυχώς, το επίπεδο γνώσεων για την ΑΔ μεταξύ οικογενειακών γιατρών και το ιατρικό προσωπικό στα τμήματα επειγόντων περιστατικών ή το ΕΚΑΒ φαίνεται να είναι χαμηλό

• (McGillivray et al, 2006). Αυτό ενισχύει την ανάγκη για την εκπαίδευση και την ενδυνάμωση των ατόμων με ΚΝΜ και τις οικογένειές τους, ώστε να μπορούν να κατευθύνουν τη θεραπεία τους.

• Επιπλέον, όλοι οι ασθενείς με ΚΝΜ πρέπει να φέρουν κάρτα υγείας έκτακτης ανάγκης για την ΑΔ.


Autonomic Dysreflexia Guideline Development Panel: Date Released1997 Feb (updated 2001 Jul; reviewed 2006)

Guideline Developer(s)Consortium for Spinal Cord Medicine - Nonprofit Organization

Paralyzed Veterans of America - Nonprofit Organization

Acute Managementof AutonomicDysreflexia:Individuals with Spinal Cord Injury Presenting to Health-Care Facilities

2nd Edition

Administrative and financial support provided by Paralyzed Veterans of AmericaPrinting provided by Eastern Paralyzed Veterans Association

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and all were excluded (i.e., were either not rele-vant or had been previously identified in the non-pediatric searches). For the extended search, 64articles were identified, of which 19 were retainedand summarized in evidence tables.

Strength of Scientific Evidence forthe Recommendations

The methodologists began by employing thehierarchy first discussed by Sackett (1989) andlater enhanced by Cook et al. (1992) and the U.S.Preventive Health Services Task Force (1996), pre-sented in table 1. Each study was evaluated forinternal and external validity. Factors affectinginternal validity (i.e., the extent to which the studyprovided valid information about the individualsand conditions studied) included sample size andstatistical power; selection bias and inclusion crite-ria; selection of control groups, if any; randomiza-tion methods and comparability of groups;definition of interventions and/or exposures; defini-tion of outcome measures; attrition rates; con-founding variables; data collection methods andobservation bias; and methods of statistical analy-sis. External validity—the extent to which thestudy findings were generalizable to conditionsother than the setting of the study—was evaluatedthrough an examination of the characteristics ofthe study population, the clinical setting and envi-ronment, and the investigators and providers ofcare. The resulting rankings were provided to thepanel members during the writing and deliberationprocess. If the literature supporting a guidelinerecommendation came from two or more levels,the level of each study is reported (e.g., in thecase of a guideline recommendation that was sup-ported by two studies, one a level III, the other alevel V, the scientific evidence was indicated as“III/V”).

Next, each of the guideline recommendationswas classified, according to the level of scientificevidence used in the development of the recom-mendation. The schema used by the panel isshown in table 2. It should be emphasized thatthese ratings, like those just described, representthe strength of the supporting evidence, not thestrength of the recommendation itself. Thestrength of the recommendation is indicated by thelanguage describing the rationale.

Category A requires that the guideline recom-mendation be supported by scientific evidencefrom at least one properly designed and imple-mented randomized, controlled trial, providing sta-tistical results that consistently support theguideline statement. Category B requires that theguideline recommendation be supported by scien-

tific evidence from at least one small randomizedtrial with uncertain results; this category also mayinclude small randomized trials with certain resultswhere statistical power is low. Category C recom-mendations are supported either by nonrandom-ized, controlled trials or by trials for which nocontrols were used (observational studies).

If a guideline recommendation was supportedby literature that crossed two categories, both cat-egories were reported (e.g., a guideline recommen-dation that included both level II and III studieswould be classified as categories B/C and be indi-cated as “grade of recommendation–B/C”). In situ-ations where no published literature existed,consensus of the panel members and outsideexpert reviewers was used to develop the guidelinerecommendation and the grade of recommenda-tion is indicated as “expert consensus.”

TABLE 2Categories of the Strength of EvidenceAssociated with the Recommendation

Category Description

A The guideline recommendation is supported byone or more level I studies

B The guideline recommendation is supported byone or more level II studies

C The guideline recommendation is supported onlyby level III, IV, or V studies

Sources: Sackett, D.L., Rules of evidence and clinical recommendations onthe use of antithrombotic agents, Chest 95 (2 Supp) (1989): 2S-4S; and U.S.Preventive Health Services Task Force, Guide to Clinical PreventiveServices: An Assessment of the Effectiveness of 169 Interventions, 2ndEdition (Baltimore: Williams and Wilkins, 1996).

6 ACUTE MANAGEMENT OF AUTONOMIC DYSREFLEXIA

TABLE 1Hierarchy of the Levels of Scientific Evidence

Level Description

I Large randomized trials with clear-cut results (andlow risk of error)

II Small randomized trials with uncertain results(and moderate to high risk of error)

III Nonrandomized trials with concurrent or contem-poraneous controls

IV Nonrandomized trials with historical controls

V Case series with no controls


and all were excluded (i.e., were either not rele-vant or had been previously identified in the non-pediatric searches). For the extended search, 64articles were identified, of which 19 were retainedand summarized in evidence tables.

Strength of Scientific Evidence forthe Recommendations

The methodologists began by employing thehierarchy first discussed by Sackett (1989) andlater enhanced by Cook et al. (1992) and the U.S.Preventive Health Services Task Force (1996), pre-sented in table 1. Each study was evaluated forinternal and external validity. Factors affectinginternal validity (i.e., the extent to which the studyprovided valid information about the individualsand conditions studied) included sample size andstatistical power; selection bias and inclusion crite-ria; selection of control groups, if any; randomiza-tion methods and comparability of groups;definition of interventions and/or exposures; defini-tion of outcome measures; attrition rates; con-founding variables; data collection methods andobservation bias; and methods of statistical analy-sis. External validity—the extent to which thestudy findings were generalizable to conditionsother than the setting of the study—was evaluatedthrough an examination of the characteristics ofthe study population, the clinical setting and envi-ronment, and the investigators and providers ofcare. The resulting rankings were provided to thepanel members during the writing and deliberationprocess. If the literature supporting a guidelinerecommendation came from two or more levels,the level of each study is reported (e.g., in thecase of a guideline recommendation that was sup-ported by two studies, one a level III, the other alevel V, the scientific evidence was indicated as“III/V”).

Next, each of the guideline recommendationswas classified, according to the level of scientificevidence used in the development of the recom-mendation. The schema used by the panel isshown in table 2. It should be emphasized thatthese ratings, like those just described, representthe strength of the supporting evidence, not thestrength of the recommendation itself. Thestrength of the recommendation is indicated by thelanguage describing the rationale.

Category A requires that the guideline recom-mendation be supported by scientific evidencefrom at least one properly designed and imple-mented randomized, controlled trial, providing sta-tistical results that consistently support theguideline statement. Category B requires that theguideline recommendation be supported by scien-

tific evidence from at least one small randomizedtrial with uncertain results; this category also mayinclude small randomized trials with certain resultswhere statistical power is low. Category C recom-mendations are supported either by nonrandom-ized, controlled trials or by trials for which nocontrols were used (observational studies).

If a guideline recommendation was supportedby literature that crossed two categories, both cat-egories were reported (e.g., a guideline recommen-dation that included both level II and III studieswould be classified as categories B/C and be indi-cated as “grade of recommendation–B/C”). In situ-ations where no published literature existed,consensus of the panel members and outsideexpert reviewers was used to develop the guidelinerecommendation and the grade of recommenda-tion is indicated as “expert consensus.”

TABLE 2Categories of the Strength of EvidenceAssociated with the Recommendation

Category Description

A The guideline recommendation is supported byone or more level I studies

B The guideline recommendation is supported byone or more level II studies

C The guideline recommendation is supported onlyby level III, IV, or V studies


6 ACUTE MANAGEMENT OF AUTONOMIC DYSREFLEXIA

TABLE 1Hierarchy of the Levels of Scientific Evidence

Level Description

I Large randomized trials with clear-cut results (andlow risk of error)

II Small randomized trials with uncertain results(and moderate to high risk of error)

III Nonrandomized trials with concurrent or contem-poraneous controls

IV Nonrandomized trials with historical controls

V Case series with no controls


Strength of Panel OpinionAfter deliberation and discussion of each

guideline recommendation and the supporting evi-dence, the level of expert panel agreement withthe recommendation was assessed as either low,moderate, or strong. In this assessment, eachpanel member was asked to indicate his or herlevel of agreement on a 5-point scale, with 1 cor-responding to neutrality and 5 representing maxi-mum agreement. Panel members could abstainfrom this voting process for a variety of reasons,such as lack of expertise associated with a particu-lar guideline recommendation. Subsequently, thescores were aggregated across the panel members,and an arithmetic mean was calculated. This meanscore was then translated into low, moderate, orstrong, as shown in table 3.

TABLE 3Levels of Panel Agreement with the GuidelineRecommendation

Level Mean Agreement Score

Low 1.0 to less than 2.33

Moderate 2.33 to less than 3.67

Strong 3.67 to 5.0

CLINICAL PRACTICE GUIDELINES 7


Autonomic Dysreflexia Guideline Development Panel: Date Released1997 Feb (updated 2001 Jul; reviewed 2006)

Guideline Developer(s)Consortium for Spinal Cord Medicine - Nonprofit Organization

Paralyzed Veterans of America - Nonprofit Organization

Recognize the signs and symptoms of autonomic dysreflexia, including:• Elevated blood pressure.• Pounding headache.• Bradycardia (may be a relative slowing so that the heart rate is still within the normal range).• Profuse sweating above the level of the lesion, especially in the face, neck, and shoulders, or

possibly below the level of the lesion.• Piloerection or goose bumps above or possibly below the level of the lesion.• Cardiac arrhythmias, atrial fibrillation, premature ventricular contractions, and atrioventricular

conduction abnormalities.• Flushing of the skin above the level of the lesion, especially in the face, neck, and shoulders, or

possibly below the level of lesion.• Blurred vision.• Appearance of spots in the patient’s visual fields.• Nasal congestion.• Feelings of apprehension or anxiety over an impending physical problem.• Minimal or no symptoms, despite a significantly elevated blood pressure (silent autonomic

dysreflexia).

Scientific evidence–None; Grade of recommendation– Expert consensus; Strength of panel opinion–Strong


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• Check the individual’s blood pressure:• A sudden, significant increase in both the systolic and diastolic blood

pressure above their usual levels, frequently associated with bradycardia. An individual with SCI above T6 often has a normal systolic blood pressure in the 90–110 mm Hg range. Therefore, a blood pressure of 20 mm to 40 mm Hg above baseline may be a sign of autonomic dysreflexia.

• Systolic blood pressure elevations more than 15–20 mm Hg above baseline in adolescents with SCI or more than 15 mm Hg above baseline in children with SCI may be a sign of AD.

Scientific evidence–III/V; Grade of recommendation–C; Strength of panel opinion–Strong


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XIA Autonomic Dysreflexia Guideline Development Panel: Date Released

1997 Feb (updated 2001 Jul; reviewed 2006)Guideline Developer(s)

Consortium for Spinal Cord Medicine - Nonprofit OrganizationParalyzed Veterans of America - Nonprofit Organization



If a pregnant woman with a spinal cord injury at T6 or above presents with signs and symptoms of autonomic dysreflexia, consider referral to an obstetric health-care provider under the following circumstances:

• Determination of choice of antihypertensive medication.• Persistent hypertension after resolution of the acute autonomic dysreflexia episode.• Persistent symptoms of autonomic dysreflexia despite acute care measures.• Life-threatening autonomic dysreflexia.• Autonomic dysreflexia episode occurring in the third trimester of pregnancy.• Hypotension requiring pharmacological treatment.• First episode of autonomic dysreflexia during the pregnancy.• Presence of vaginal bleeding or suspicion of labor.• Decisions to be made about long-term medication use.• Unclear about the causes, signs, and symptoms, despite a normal blood pressure.



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• If signs or symptoms of AD are present, but the blood pressure is not elevated and the cause has not been identified, refer the individual to an appropriate consultant depending on symptoms.

• Other medical problems may be causing the signs and symptoms of autonomic dysreflexia.

Scientific evidence–None; Grade of recommendation–- Expert consensus; Strength of panel opinion–Strong


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• If the blood pressure is elevated, immediately sit the person up if the individual is supine.Scientific evidence–III/V; Grade of recommendation–C; Strength of panel opinion–Strong

•Loosen any clothing or constrictive devices.Scientific evidence–III/V; Grade of recommendation–C; Strength of panel opinion–Strong

•Monitor the blood pressure and pulse frequently.Scientific evidence–III/V; Grade of recommendation–C; Strength of panel opinion–Strong

•Quickly survey the individual for the instigating causes, beginning with the urinary system.Scientific evidence–III/V; Grade of recommendation–C; Strength of panel opinion–Strong

• If an indwelling urinary catheter is not in place, catheterize the individual.Scientific evidence–None; Grade of recommendation–Expert consensus; Strength of panel opinion–Strong

• Prior to inserting the catheter, instill 2 percent lidocaine jelly (if immediately available) into the urethra and wait 2 minutes, if possible.Scientific evidence–None; Grade of recommendation– Expert consensus; Strength of panel opinion–Strong


If fecal impaction is suspected and the elevated blood pressure is less than 150 mm Hg, check the rectum for stool, using the following procedure:

• With a gloved hand, instill a topical anesthetic agent, such as 2 percent lidocaine jelly, generously into the rectum.

• Wait 2 minutes if possible for sensation in the area to decrease.• Then, with a gloved hand, insert a lubricated finger into the rectum and

check for the presence of stool. If present, gently remove, if possible.• If autonomic dysreflexia becomes worse, stop the manual evacuation.

Instill additional topical anesthetic and recheck the rectum for the presence of stool after approximately 20 minutes.

Scientific evidence–II/V; Grade of recommendation–B/C; Strength of panel opinion–Strong


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• Use an antihypertensive agent with rapid onset and short duration while the causes are being investigated & BP a systolic blood pressure >150mmHg

• 120 mm Hg in infants and younger children (under 5 years old)• 130 mm Hg in older children (6–12 years old)• 140 mm Hg in adolescents

Scientific evidence–V; Grade of recommendation–C; Strength of panel opinion–Strong

• Monitor the individual for symptomatic hypotension.



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Therapeutic management of Autonomic DysreflexiaAndrei Krassioukov

International Collaboration on Repair Discoveries (ICORD), Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia,

and GF Strong Rehab Centre, Vancouver, Canada.review of 40 studies (6 RCTs):

THERAPEUTIC MANAGEMENTof acute AD LEVEL OF EVIDENCE

Preventative strategies to reduce the episodes of AD caused by common triggers (e.g. urogenital system, surgery)

Level 4 (pre-post studies)

Level 5 (observational studies)

initial acute non-pharmacological management of an episode of AD (i.e. positioning the patient upright, loosening tight clothing, and eliminating any precipitating stimulus)

Level 5 (clinical consensus and physiological data)

use of antihypertensive drugs in the presence of sustained elevated blood pressure

Level 2 evidence (nifedipine and prostaglandin E2)Level 5 (nitrates)Level 4 (captopril)Level 1 (prazosin)


• Following an episode of autonomic dysreflexia, instruct the individual to monitor symptoms and blood pressure for at least 2 hours after resolution of the episode to make sure that it does not reoccur.

• Educate the individual to seek immediate medical attention if it reoccurs.

• Monitor inpatients closely for at least 2 hours, as deemed necessary by the health-care provider.

• Seek the pregnant woman’s obstetrical- care provider for evaluation.



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Consider admitting the individual to the hospital for monitoring to maintain pharmacologic control of the blood pressure, and to investigate other causes:

• If there is poor response to the treatment specified above.• If the cause has not been identified.• If there is suspicion of an obstetrical complication.

Scientific evidence–V; Grade of recommendation–C; Strength of panel opinion–Strong


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Schedule detailed evaluations for individuals with recurrent autonomic dysreflexia.

• a worsening of detrusor sphincter dyssynergia • an expanding syrinx



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• Εκτός από τα σημεία και τα συμπτώματα που παρατηρούνται σε ενήλικες, τα βρέφη και τα παιδιά μπορεί να παρουσιάσουν μη ειδικά συμπτώματα, όπως κλάμα, ευερεθιστότητα ή υπνηλία.

• Οι γονείς των μικρών παιδιών, εκπαιδευτικοί, σχολικές νοσοκόμες, προπονητές, πάροχοι πρωτοβάθμιας περίθαλψης θα πρέπει να έχουν την κατάλληλη εκπαίδευση.

• Όταν μια γυναίκα με κάκωση νωτιαίου μυελού > T6 μείνει έγκυος, τη φροντίδα της θα πρέπει να συντονίζει μια διεπιστημονική ομάδα. Συνιστάται η ομάδα αυτή να αναπτύξει ένα σχέδιο για τη διαχείριση των δυσρηφλέξιας.


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preventive process entails:• Adjusting the treatment plan to ensure that future episodes are

recognized and treated to prevent a medical crisis or, ideally, are avoided altogether.

• Discussing autonomic dysreflexia during the individual’s education program, so that he or she will be able to minimize the risks known to precipitate AD, solve problems, recognize early onset, and obtain help as quickly as possible.

• Providing the individual with education about the prevention and treatment of autonomic dysreflexia at the time of discharge that can be referred to in an emergency.



Therapeutic management of Autonomic DysreflexiaAndrei Krassioukov

International Collaboration on Repair Discoveries (ICORD), Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia,

and GF Strong Rehab Centre, Vancouver, Canada.review of 40 studies (6 RCTs):

THERAPEUTIC MANAGEMENTprevention of AD LEVEL OF EVIDENCE

Education on the causes of AD, appropriate bladder and bowel routines, and pressure ulcer prevention appear to be the most effective measures for prevention of AD in subjects with SCI

??

control of detrusor hyperreflexia & DSD: anticholinergics, IVES BT-A, augmentation enterocystoplasty

??

use of antihypertensive drugs in the presence of sustained elevated blood pressure

alpha 1 blockers:Level 4 (terazocin- Hytrin)Level 1 (prazosin- Minipress)


ΠΡΟΛΗΨΗ ΕΠΕΙΣΟΔΙΩΝ ΑΔ• συχνή ανακούφιση σε σημεία πίεσης (push ups,

αλλαγές θέσεων στο κρεββάτι)

• αποφυγή εγκαυμάτων/ηλιοθεραπείας, χρήση κρέμας με δείκτη προστασίας >15, προσοχή στην θερμοκρασία νερού

• πιστή προσήλωση στο τακτικό πρόγραμμα κένωσης εντέρου

• πιστή προσήλωση στο τακτικό πρόγραμμα κένωσης κύστεως, τακτική καθαριότητα μόνιμων καθετήρων

• ισορροπημένη δίαιτα και πρόσληψη υγρών

• τακτική λήψη της φαρμακευτικής αγωγής


ΠΡΟΛΗΨΗ ΕΠΕΙΣΟΔΙΩΝ ΑΔ• προσοχή στα “τσακίσματα” του καθετήρα

• τακτικό άδειασμα ουροσυλλέκτη

• CISC: συχνοι καθετηριασμοί για την αποφυγή υπερπλήρωσης

• αντανακλαστική ούρηση: παρακολούθηση της τακτικής αποβολής ούρων

• διαθέσιμο πάντα CISC kit

• τακτικό πρόγραμμα κένωσης εντέρου

• τακτικός έλεγχος δέρματός για τυχόν κακώσεις ή έλκη πίεσης

• τακτική ετήσια παρακολούθηση



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AUTONOMIC DYSREFLEXIA:WHAT YOU SHOULD KNOW

A Guide for People with

Consortium for Spinal Cord MedicineAdministrative and financial support provided by Paralyzed Veterans of America


AUTONOMIC DYSREFLEXIA:WHAT YOU SHOULD KNOW

A Guide for People with

Consortium for Spinal Cord MedicineAdministrative and financial support provided by Paralyzed Veterans of America

What to Do If You Think You HaveAutonomic Dysreflexia:Prompt action is essential! If you can’t follow these steps yourself, tell afamily member, an attendant, or a friend what to do. It’s important to dothese steps in the order below.

1. Sit up, or raise your head to 90 degrees. If you can lower your legs, do.

2. Loosen or take off anything tight:

! External catheter tape

! Clothes

! Elastic hose or bandages

3. If you have a blood pressure kit, take your blood pressure read-ing about every 5 minutes to see if you’re getting better.

4. Check to see if your bladder is draining properly (see page 4, step 4).

5. Call your health-care professional, even if the warning signs go away. Report the symptoms you had and what you did to correct the problem.

6. If the warning signs come back again, repeat these steps. Even if the warning signs go away again, call your health-care professional and go to the emergency room.

7. At the emergency room, make sure you:

! Tell the emergency room staff that you think you may have autonomic dysreflexia and need immediate treatment.

! Ask to have your blood pressure checked immediately.

! Request to keep sitting up as long as your blood pressure is high.

! Ask the emergency room staff to look for causes of the problem. Suggest that they check for causes in this order: (1) bladder,(2) bowel, and (3) other causes.

! Suggest that your health-care professional instill anesthetic jelly into your rectum before checking your bowel.

Important: Inform the emergency room staff that there is a complete clinical practice guideline available at the website: www.pva.org.

! Abdominal binders

! Shoes or leg braces

! Leg bag straps

Important: You need to stay sitting or upright until your blood pressure is back to normal.


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My Personal Autonomic Dysreflexia Diary

This Personal Diary is intended for you to use to keep a health-care record of yourepisodes of autonomic dysreflexia. Another copy of the Diary, which you can photo-copy for re-use, appears in the back pocket of this Guide. Keep this diary and the Guide with you.

Name:

Address:

City State: Zip Code:

Phone Number: ( )

Social Security Number: Date of Birth:

Date of Dysreflexia Episode:

SymptomsPut a checkmark or "X" next to every symptom you have for each dysreflexia episode.

! Pounding headache

! Heavy sweating

! Flushed skin

! Goose bumps

! Blurry vision

! Seeing spots

! Stuffy nose

! Anxiety or jitters

Cause of Dysreflexia Episode and Comments:

! Tight chest

! Trouble breathing

Other:

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! Pounding headache

! Heavy sweating

! Flushed skin

! Goose bumps

! Blurry vision

! Seeing spots

! Stuffy nose



! Tight chest

! Trouble breathing

Other:



! Pounding headache

! Heavy sweating

! Flushed skin

! Goose bumps

! Blurry vision

! Seeing spots

! Stuffy nose



! Tight chest

! Trouble breathing

Other:


ΡΑΠΙΔΗ AD, 2013, 12ο Β'ΦΙΑπ

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