C6/7 quadriplegia, endoscopies

Consult: 53-year-old man for gastroscopy and colonoscopy 


  • New dyspepsia, post-prandial abdominal pain, and positive faecal-occult blood test.
  • DVT/PE – provoked during hospital admissions. On Lifelong warfarin.


  • Incomplete C6/C7 quadriplegia following an MBA aged 17
  • Autonomic Dysreflexia – multiple episodes documented during hospital admissions and procedures. 
  • BP at clinic – 178/106. Asymptomatic.
  • CKD – stage 4. On Hemodialysis x 3 per week. Anuria, hyperkalemia pre-dialysis up to 6.1mmol/L. FR 1000ml


Autonomic Dysreflexia

  • Patient reports no events at home for many years. Has GTN spray which has never used
  • States rarely gets headaches but has felt sweaty and hot in the past during episodes
  • Previous anaesthetic charts documented multiple episodes of hypertension both with and without flushing/headache/diaphoresis
  • HR often raised or normal during these episodes
  • Possible that patient has untreated hypertension in the setting of stage 4 kidney disease and hypertension may not always be attributed to autonomic dysreflexia

Conduct of Anaesthesia

  • Discussion centered on management of sedation for procedure. Consensus that THRIVE, local spray to throat, and sedation would be preferred
  • Noted that patient may be very sensitive to benzodiazepines and opioids
  • However, propofol alone unlikely to be adequate
  • Remifentanil suggested as an option to blunt sympathetic response. 

Bowel preparation/Fluid balance 

  • Planned for admission the day before, dialysis and then bowel preparation as an inpatient
  • Patient agrees it would be very difficult to perform bowel preparation at home
  • Will require careful fluid balance and electrolyte monitoring
  • Essential that we avoid dehydration (as well as fluid overload)
  • Consider overnight stay post-operatively to monitor fluid balance and facilitate dialysis if required.


  • Proceed with surgery
  • Liaise with GP and renal physician regarding hypertension
  • Admit to hospital the day before.