Epidurals, Ethics, and Expectations: Talking Risks and Benefits in Obstetric Anesthesia

Autonomic dysreflexia (AD) is medical emergency commonly seen in patients with a T6 or higher spinal cord injury. Initially after spinal cord injury there is hypotension and bradycardia but after this period exaggerated reflexes are thought to develop that lead to an autonomic imbalance resulting in splanchnic and peripheral vasoconstriction with noxious stimuli. Most commonly there is severe hypertension with bradycardia. Flushing, blotching, nasal congestion and sweating are seen above the level of injury as a compensatory mechanism. The most common trigger (85%) of autonomic dysreflexia includes genitourinary issues such as bladder distension or procedures. The second most common precipitating factor is gastrointestinal pathology such as constipation. Prophylaxis against these episodes consists of wearing loose fitting clothing, good urological and gastrointestinal care, and alpha adrenoceptor blockade with medication such as terazosin or prazosin. A neuraxial technique (or general anesthetic) can be used in patients who are susceptible to AD and may be appropriate.