Study Design: Retrospective chart review. Objective: To compare autonomic dysreflexia (AD) severity during urodynamics and cystoscopy in individuals with spinal cord injury (SCI). Setting: Outpatient urological clinic. Methods: Demographic and clinical data were collected from charts of individuals with SCI who had blood pressure (BP) monitoring during urological procedures. Cardiovascular parameters were collected at baseline and during the various stages of two examinations. Results: A total of 21 SCI individuals (mean age 49.4 years) who underwent both procedures developed episodes of AD. The majority of individuals had cervical SCI (85.7%). The median duration of injury was 183 months (ranging from 3 to 530 months). There was statistically more of an increase (P ¼ 0.039) in systolic BP during cystoscopy (67.1 ± 33.8 mm Hg) in comparison with urodynamics (51.8±21.8 mm Hg). The BP response during episodes of AD was more pronounced in individuals with more than 2 years post SCI than with less than 2 years post SCI during both urodynamics and cystoscopy (P ¼ 0.047 and P ¼ 0.010, respectively). Conclusion: Even though cystoscopy filled the bladder to lesser volumes than did urodynamics (150 ml vs 500 ml), during cystoscopy the individuals developed greater changes in systolic BP, indicating that stimulation of the urethra/prostate/internal sphincter region probably is a more potent stimulus of AD than just the filling of the bladder. The severity of AD also increased with time post SCI during both procedures. Considering the high incidence of silent episodes of AD during the urological procedures, it is recommended that monitoring of cardiovascular parameters during these procedures be routinely performed. One of the most common physician-induced causes of AD in individuals with SCI is the use of procedures that involve urinary bladder and urogenital areas. 3 Previously, numerous studies using different groups of individuals with SCI examined CV responses either during urodynamic 3-6 or cystoscopic examination. 7,8 These two procedures both involve urinary bladder distension. However, cystoscopy includes greater stimulation of the urethra and bladder neck afferents during the procedure through urethral/prostate/ internal sphincter passage and dilation, which could then provide more intense afferent stimulation to the spinal cord and trigger more pronounced episodes of AD. Considering the physiological difference
The aim of the present study was to determine whether lung volume recruitment (LVR) acutely increases respiratory system compliance (Crs) in individuals with severe respiratory muscle weakness (RMW).Individuals with RMW resulting from neuromuscular disease or quadriplegia (n=12) and healthy controls (n=12) underwent pulmonary function testing and the measurement of Crs at baseline, immediately after, 1 h after and 2 h after a single standardised session of LVR. The LVR session involved 10 consecutive supramaximal lung inflations with a manual resuscitation bag to the highest tolerable mouth pressure or a maximum of 50 cmH2O. Each LVR inflation was followed by brief breath-hold and a maximal expiration to residual volume.At baseline, individuals with RMW had lower Crs than controls (37±5 cmH2O versus 109±10 mL·cmH2O−1, p<0.001). Immediately after LVR, Crs increased by 39.5±9.8% to 50±7 mL·cmH2O−1 in individuals with RMW (p<0.05), while no significant change occurred in controls (p=0.23). At 1 h and 2 h post-treatment, there were no within-group differences in Crs compared to baseline (all p>0.05). LVR had no significant effect on measures of pulmonary function at any time point in either group (all p>0.05). During inflations, mean arterial pressure decreased significantly relative to baseline by 10.4±2.8 mmHg and 17.3±3.0 mmHg in individuals with RMW and controls, respectively (both p<0.05).LVR acutely increases Crs in individuals with RMW. However, the high airway pressures during inflations cause reductions in mean arterial pressure that should be considered when applying this technique.
Bladder-related events, including neurogenic detrusor overactivity, are the leading cause of autonomic dysreflexia in spinal cord injured individuals. Self-reported autonomic dysreflexia is reduced following onabotulinumtoxinA treatment for neurogenic detrusor overactivity; however, none of these trials have assessed autonomic dysreflexia events using the clinical cutoff of an increase in systolic blood pressure ≥20 mm Hg. This study used a prospective, open-labelled design from 2013 to 2014 to quantitatively assess the efficacy of one cycle 200 U intradetrusor-injected onabotulinumtoxinA (20 sites) on reducing the severity and frequency of bladder-related autonomic dysreflexia events and improving quality of life. Twelve men and five women with chronic, traumatic spinal cord injuries at or above the sixth thoracic level, and concomitant autonomic dysreflexia and neurogenic detrusor overactivity, underwent blood pressure monitoring during urodynamics and over a 24 h period using ambulatory blood pressure monitoring pre- and 1 month post-treatment. Post-onabotulinumtoxinA, autonomic dysreflexia severity was reduced during urodynamics (systolic blood pressure increase: 42 ± 23 mm Hg vs. 20 ± 10 mm Hg, p < 0.001) and during bladder-related events across the 24 h period (systolic blood pressure increase: 49 ± 2 mm Hg vs. 26 ± 22 mm Hg, p = 0.004). Frequency of 24 h bladder-related autonomic dysreflexia events was also decreased post-onabotulinumtoxinA (4 ± 2 events vs. 1 ± 1 events, p < 0.001). Autonomic dysreflexia and incontinence quality of life indices were also improved post-onabotulinumtoxinA (p < 0.05). Intradetrusor injections of onabotulinumtoxinA for the management of neurogenic detrusor overactivity in individuals with high level spinal cord injuries decreased the severity and frequency of bladder-related episodes of autonomic dysreflexia, and improved bladder function and quality of life.
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