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
- 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.