title: Are urological procedures in tetraplegic patients safely performed without anesthesia? a report of three cases.
abstract: BACKGROUND
  Some tetraplegic patients may wish to undergo urological procedures without anaesthesia, but these patients can develop autonomic dysreflexia if cystoscopy and vesical lithotripsy are performed without anaesthesia.
  
  
  METHODS
  We describe three tetraplegic patients, who developed autonomic dysreflexia when cystoscopy and laser lithotripsy were carried out without anesthesia.In two patients, who declined anaesthesia, blood pressure increased to more than 200/110 mmHg during cystoscopy. One of these patients developed severe bleeding from bladder mucosa and lithotripsy was abandoned. Laser lithotripsy was carried out under subarachnoid block a week later in this patient, and this patient did not develop autonomic dysreflexia.The third patient with C-3 tetraplegia had undergone correction of kyphoscoliotic deformity of spine with spinal rods and pedicular screws from the level of T-2 to S-2. Pulmonary function test revealed moderate to severe restricted curve. This patient developed vesical calculus and did not wish to have general anaesthesia because of possible need for respiratory support post-operatively. Subarachnoid block was not considered in view of previous spinal fixation. When cystoscopy and laser lithotripsy were carried out under sedation, blood pressure increased from 110/50 mmHg to 160/80 mmHg.
  
  
  CONCLUSIONS
  These cases show that tetraplegic patients are likely to develop autonomic dysreflexia during cystoscopy and vesical lithotripsy, performed without anaesthesia. Health professionals should educate spinal cord injury patients regarding risks of autonomic dysreflexia, when urological procedures are carried out without anaesthesia. If spinal cord injury patients are made aware of potentially life-threatening complications of autonomic dysreflexia, they are less likely to decline anaesthesia for urological procedures. Subrachnoid block or epidural meperidine blocks nociceptive impulses from urinary bladder and prevents occurrence of autonomic dysreflexia. If spinal cord injury patients with lesions above T-6 decline anaesthesia, nifedipine 10 mg should be given sublingually prior to cystoscopy to prevent increase in blood pressure due to autonomic dysreflexia.
authors.affiliation: Regional Spinal Injuries Centre, Southport and Formby District General Hospital, Town Lane, Southport PR8 6PN, UK. subramanian.vaidyanathan@nhs.net.
authors.forename: Subramanian
authors.initials: S
authors.lastname: Vaidyanathan
authors.forename: Bakul
authors.initials: B
authors.lastname: Soni
authors.forename: Fahed
authors.initials: F
authors.lastname: Selmi
authors.forename: Gurpreet
authors.initials: G
authors.lastname: Singh
authors.forename: Cristian
authors.initials: C
authors.lastname: Esanu
authors.forename: Peter
authors.initials: P
authors.lastname: Hughes
authors.forename: Tun
authors.initials: T
authors.lastname: Oo
authors.forename: Kamesh
authors.initials: K
authors.lastname: Pulya