Tag Archives: autonomic dysreflexia

Bladder Washout Kit

Bladder Washout

A bladder washout is a technique used to flush blood clots or debris from the bladder by pushing water solution into the bladder and immediately draining.

Who Requires a Bladder Washout

You may need a bladder washout if:

  • You have a lot of sediment in your urine
  • You are unsure if your catheter is draining correctly
  • Your catheter has blocked and you have no replacemnent
  • You have been advised by your doctor or community nurse to do bladder washouts in the treatment of a specific urinary tract infection

Advantages of a Bladder Washout

  • If you are unable to drink large amounts of fluids to treat a urinary tract infection or heavy sediment this may be an alternative method
  • If your catheter repeatedly blocks off and you are unwilling or unable to do frequent catheter changes
  • Stretching the bladder frequently can help avoid shrinkage

Disadvantages of a Bladder Washout

  • Every time you disconnect a catheter from drainage bag you create an entry point for infection
  • You are introducing foreign fluid into your bladder
  • The procedure is time consuming
  • If not done carefully it can cause bleeding and blood clots
  • There is risk of damage to the epithelial lining of the bladder
  • Studies have shown it has little or no effect on most infections
  • Bladder washouts may induce autonomic dysreflexia in quadriplegics

Bladder Washout Equipment

  • 60ml plastic syringe
  • 2 clean plastic trays (ice cream containers or similar)
  • 500mls of sterile bottled water or treated tap water boiled and cooled to room temperature (not* bore water tank water or chlorhexidine)
  • Small supply of cotton wool balls
  • Alcohol wipes (or small amount of methylated spirits or sterilizer for swabbing the catheter connections only)
  • Clean bench area
Bladder Washout Kit

Bladder Washout Kit

Bladder Washout Procedure

If you experience pain at any time during the bladder washout procedure you should cease immediately and call a doctor or paramedic!

  1. Select a clean area where the procedure is to be carried out. (We suggest a bench area in the bathroom with a clean towel over the top of it).
  2. This procedure can either be carried out by the patient or their carer – the instructions are the same for both.
  3. Take the 500mls of prepared water and place within reach on the bench. Ensure the second container is alongside the first as this will be used for the used irrigation fluid and urine that is ‘washed out’ of the bladder during the procedure.
  4. Place the clean 60ml syringe alongside the containers on the prepared area. This is used to insert the water into the bladder.
  5. Place the cotton balls beside the container and have the methylated spirits within reach.
  6. Ensure the connection between the catheter and the drainage bag is exposed so you can get to it easily.
  7. Wash your hands thoroughly.
  8. Take a cotton ball soaked with methylated spirits and wipe the connection thoroughly. Dispose of the cotton ball.
  9. Carefully take the connection apart and rest the catheter end in the empty container.
  10. Fill the syringe with 60mls of water from the water container. Insert the syringe into the end of the catheter and gently insert the water by pressing on the plunger of the syringe. Do not withdraw any fluid through the catheter at this stage.
  11. Remove the syringe being careful to put the open catheter end into the empty container. You will notice that some of the urine/water will drain into the container.
  12. Fill the syringe again with 60mls of water and insert into the bladder. Once the syringe is completely empty withdraw 40mls of the mixture of urine/water into the syringe then discard into the drainage container. Again you will notice there is drainage of urine/water from the catheter into the drainage container.
  13. Repeat step 12 until all 500mls of water has been used.
  14. On completion take another cotton wool ball soaked with methylated spirits and wipe the catheter connection again before reconnecting to the drainage bag.
  15. Discard urine/water into the toilet and using a small amount of disinfectant clean out the container.
  16. Both containers should be kept covered and scalded out once a week with boiling water.

Care of Bladder Washout Equipment

You will need to make fresh milton solution each time you sterilise your bladder washout equipment before and after each procedure by doing the following;

  • Into your clean water container place 500mls of tap water and either ¼ milton tablet or 7mls of milton solution (you can use vinegar and clean water at a 1:10 ratio or gently boil the equipment for 5 minutes)
  • Once the solution has mixed place syringe with plunger removed from main barrel into this solution
  • Leave the syringe to soak in the solution for one hour
  • After one hour remove syringe and discard milton solution from container
  • Using a clean towel or disposable paper towel dry container and syringe and store syringe in sealed container

Resources

  • The Spinal Injuries Unit: Phone (07) 3240 2215 or (07) 3240 2641
  • The SIU Consultant on Call Through PAH switchboard (after hours)
  • Queensland Spinal Cord Injuries Service: www.health.qld.gov.au/qscis

Autonomic Dysreflexia – Hyperreflexia

When a strong sensory impulse is sent via the spinal cord to the brain it envokes a massive sympathetic reflex and hypertension. Blood pressure rises often resulting in chronic headaches, blurred vision, blotchy skin and sweating. Also known as hyperreflexia, autonomic dysreflexia is a potentially life threatening condition usually affecting individuals with spinal cord injury from a lesion at or above the T6 neurological level. Common amongst quadriplegics early recognition of symptoms and treament can avoid the associated dangers of elevated blood pressure, brain hemorrhage, burst blood vessels, stroke and fitting. If you suffer from autonomic dysreflexia it’s important to educate family, carers and medical professionals about the syndrome and its management.

Epidemiology Of Autonomic Dysreflexia

Dysreflexic Headache

Dysreflexia causes chronic headaches

Below the level of spinal cord injury intact peripheral sensory nerves transmit impulses that ascend in the spinothalamic and posterior columns to stimulate sympathetic neurons located in the intermediolateral gray matter of the spinal cord. A sympathetic production of various neurotransmitters (norepinephrine, dopamine-b-hydroxylase, dopamine) from cerebral vasomotor centres increases but typically are unable to pass below the level of spinal cord injury. Vasoconstriction (narrowing) in arterial vasculature below the SCI and vasodilation (widening) of pain sensitive intracranial vessels above the SCI occurs creating severe headaches.

Vasomotor brainstem reflexes attempt to lower blood pressure by increasing parasympathetic stimulation to the heart through the vagus nerve to cause compensatory bradycardia. This reflex action cannot compensate for severe vasoconstriction, explained by the Poiseuille formula where pressure in a tube is affected to the fourth power by change in radius (vasoconstriction) and only linearly by change in flow rate (bradycardia). Parasympathetic nerves may also prevail above the level of injury which may be characterized by profuse sweating. Vasodilation may also display as blotchy skin, blurred vision and so on. Once the inciting stimulus is removed, reflex hypertension (hyperreflexia) resolves.

Autonomic Dysreflexia In Plain English

When a person with a spinal cord injury (lesion) at or above T6 such as a quadriplegic or tetraplegic breaks their leg the pain messages sent to the brain which usually have you on the ground screaming get mixed up and lost. I often explain it as cutting through a telephone cable with 100,000 wires in it, twist one side 90 degrees and press them back together. Not much chance your call will get through and if it does it will probably be a wrong number.

Finding the source of dysreflexia

Finding the source of dysreflexia

Two years ago I broke my Tibia (shinbone) clean in half and fractured Fibula (thinner one behind it). Broken leg pain messages reached my damaged spinal cord area near C4 and couldn’t go any further. I only knew it was broken because it went off like a firecracker, snap! The message “this hurts” from my leg got transposed at the damaged section C4 of my spinal cord into let’s raise his blood pressure. I developed a mild headache and later a little sweating — autonomic dysreflexia.

An average blood pressure for people with a T6 spinal injury is commonly 90-100/60 when lying and lower when sitting. A BP of 130/90 is considered slightly high and if untreated it can rapidly rise to extreme dangerous levels like 220/140. I myself with C4 quadriplegia once hit 220/160 due to a blocked catheter. I displayed all the classic symptoms. Luckily once layed on a bed the blockage released filling a 2 litre drainage bag in a matter of minutes. I gained instant relief. You would think a badly broken leg would have been worse, but not in my case. Not everyone with a T6 or higher level of spinal cord injury experiences autonomic dysreflexia and the severity will vary per person but in all cases where it does occur it warrants immediate attention.

Common Autonomic Dysreflexia Symptoms

  • Blotchy red, rash like, flushing skin
  • Blurred vision
  • Headache
  • High blood pressure

Possible Autonomic Dysreflexia Symptoms

  • A sudden significant rise in systolic and diastolic blood pressures (usually associated with bradycardia). The normal systolic blood pressure for SCI above T6 is 90-100mm Hg
  • Difficulty breathing
  • Dizzyness
  • Goose bumps above or below the level of the spinal cord injury
  • Nasal congestion
  • Profuse sweating above the level of lesion especially in the face neck and shoulders may be noted but rarely occurs below the level of spinal cord injury because of sympathetic cholinergic activity
  • Spots may appear in the persons visual fields

Occassionaly no symptoms are observed besides elevated blood pressure. Dysreflexic episodes can be triggered by many things though painful, strong irritating stimulus below the level of the spinal cord injury are most frequently the cause of an autonomic dysreflexic reaction.

Causes Of Autonomic Dysreflexia

  • Appendicitis or other abdominal pathology trauma
  • Bladder distension
  • Blisters
  • Blocked catheter
  • Bowel distension
  • Bowel impaction
  • Broken bones fractures or other trauma
  • Burns or sunburn
  • Constrictive clothing shoes or appliances
  • Contact with hard or sharp objects
  • Cystoscopy
  • Deep vein thrombosis (blood clot in vien or artery)
  • Detrusor-sphincter dyssynergia
  • Ejaculation
  • Epididymitis or scrotal compression
  • Gall, bladder or kidney stones
  • Gastric ulcers or gastritis
  • Gastrocolic irritation
  • Hemorrhoids
  • Heterotopic bone
  • Ingrown toenail
  • Insect bites
  • Invasive testing
  • Menstruation
  • Pain
  • Pregnancy, especially labor and delivery
  • Pressure sores or ulcers
  • Pulmonary embolism (blood clot in lungs)
  • Sexual intercourse
  • Sudden temperature changes
  • Surgical or diagnostic procedures
  • Testicular compression
  • Urinary tract infection
  • Urodynamics
  • Vaginitis

It is easier to assist a dysreflexic person when two carers are present, one can monitor blood pressure while the other provides treatment, but this may not always be possible. The person with a spinal cord injury is usually aware of dysreflexia and will often be able to suggest possible causes. In any case it is important that the symptoms are relieved quickly and their BP lowered. Treat all episodes of autonomic dysreflexia as a medical emergency but stay calm and avoid leaving the person alone.

Initial Treatments For Autonomic Dysreflexia

  • Ask if they have just taken a drug to control autonomic dysreflexia
  • Ask the individual and carer if they suspect a cause
  • Elevate the head and lower legs if possible (this will help lower BP until a cause is identified)
  • Loosen any constrictive clothing
  • Check bladder drainage equipment for kinks or other causes of obstruction to flow such as catheter blockage, leg bag problems or an overfull leg bag
  • Monitor BP every 2-5 minutes
  • Avoid pressing?on the bladder

Further Treatments Of Autonomic Dysreflexia

If the person has an Indwelling Catheter or Supra Pubic Catheter:

  • Empty urinary drainage devivce and determine whether or not the bladder is empty, ask if volume is reasonable considering fluid intake and output earlier that day
  • If the catheter is blocked, irrigate GENTLY with no more than 30 mls of sterile water. Drain the bladder slowly, 500 ml initially and 250 ml each 15 minutes afterwards to avoid a sudden drop in blood pressure
  • If this is unsuccessful recatheterize using a generous amount of lubricant containing a local anaesthetic e.g. 2% lignocaine (Xylocaine) jelly
  • Where constipation is suspected check the rectum for faecal loading
  • If the rectum is full check the blood pressure before attempting manual evacuation
  • Gently insert a generous amount of lignocaine jelly into the rectum and gently remove the faecal mass – note: if symptoms are aggravated stop immediately and seek an alternate method of evacuation such as supositories or laxettes

If elevated blood pressure does not start to fall within one or two (1-2) minutes of the above proceedures and the cause cannot be determined treatment with a short-acting anti-hypertensive medication should be commenced concurrently with the search for and treatment of the cause. The blood pressure threshold at which medication should be given may vary a little depending on the individual and type of intervention being undertaken. In general if a systolic blood pressure greater than 170mm prevails consider use of a blood pressure lowering medication.

Glyceryl Trinitrate 

NB: DO NOT use glyceryl trinitrate if sildenafil (Viagra), or vardenafil (Levitra) has been taken in the previous 24 hours or tadalafil (Cialis) in the previous 4 days. Give one spray of glyceryl trinitrate (Nitrolingual Pumpspray) under the tongue. During administration the canister should be held upright and the spray should not be inhaled.

OR: Place a glyceryl trinitrate tablet (Anginine) under the tongue.

OR: Apply 5mg, transdermal patch to chest and upper arms according to manufacturer’s instructions. Remove patch once BP settles or if the BP drops too low.

A hypotensive response (lower blood pressure) should begin within 2 to 3 minutes and last up to 30 minutes. A second spray/tablet may be given in 5 -10 minutes if the reduction in the blood pressure is inadequate or if the blood pressure rises again. If glyceryl trinitrate is not available or unsuitable (e.g. within 24 hours of sildenafil use) give one 10 mg nifedipine tablet (not a slow-release tablet) crushed, mixed with water and swallowed. Avoid sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis) for at least 48 hours after a severe episode of autonomic dysreflexia.

Botox Trials On Autonomic Dysreflexia

A Taiwanese study recently indicated that for patients with Spinal Cord Injury who have detrusor sphincter dyssynergia, using a combination of fluoroscopy and electromyography to localize the external urethral sphincter with a Foley catheter employed to visualize vesicourethral anatomy, makes transperineal injection of botulinum toxin (botox) type A into the external urethral sphincter safe accurate and easy to perform. Such injections have been shown to reduce the occurrence and severity of autonomic dysreflexia as well as vesicoureteral reflux, hydronephrosis, and urinary tract infection.

Kind Regards
Graham Streets
MSC Founder

Resources

  • Autonomic Dysreflexia in Spinal Cord Injury : Treatment & Medication by Denise I Campagnolo. Barrow Neurology Clinics. St Joseph’s Hospital and Medical Center. Investigator for Barrow Neurology Clinics.
  • Director NARCOMS Project for Consortium of MS Centers.