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

Background

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

Issues:

• 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

Discussion

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.

Plan:

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