Autonomic Dysreflexia safe management of bladder and bowel care procedure

1 Aim

Autonomic Dysreflexia (AD) is characterised by a sudden rise in blood pressure which may lead onto a cerebral haemorrhage (stroke) and even death. It must always be treated as a medical emergency. Those that are at risk of AD are individuals with a spinal cord injury above T6.

Within a normal functioning nervous system, blood pressure rises when the body encounters a harmful stimulus. The nervous system responds via the autonomic nervous system, which results in dilation of the blood vessels, this in turn lowers the blood pressure and the body circulation remains in a safe and static state.

Patients with a spinal cord injury located at thoracic spinal level 6 (T6) the ability of the autonomic nervous system to response normally is affected. As a result the autonomic system cannot lower the blood pressure in response to the pain or discomfort below the level of the spinal cord injury. Blood pressure will continue to rise until the stimulus is removed. This can place the patient at risk of cerebral haemorrhage if not managed appropriately.

Patients with spinal cord injuries or neurological conditions may have neurogenic bladder or bowel dysfunction, which often means they need to have routine interventional bladder and bowel care, including procedures such as digital removal of faeces (DRF) and catheterisation. This intervention may stimulate the response, so it is vital that all clinical staff have an awareness of AD and the actions required to manage the situation as described in this procedure. Staff must be competent in undertaking bladder and bowel management.

Baseline blood pressure must be obtained and recorded in clinical care records and a reminder (alert) also documented to ensure all staff are aware of the potential risk.

A clear, individualised care plan should be in place for safe management of bladder and bowel care.

Non-adherence to a patient’s usual bladder and bowel care regime can cause an onset of AD. Therefore, it is vital that bladder and bowel care is a priority for all these patients to ensure that their health and dignity are maintained.

2 Scope

This procedure applies to all Doncaster care group staff, whether in a direct or indirect patient care role.

Adherence to the procedure is the responsibility of all Doncaster care group staff, including agency, locum and bank staff.

For Rotherham and North Lincolnshire staff you should refer to your local guidelines.

Autonomic dysreflexia is not a disorder of bladder and bowel dysfunction and this procedure should be used as part of a comprehensive and wide care plan developed for the individual patient in relation to their own spinal cord injury and consequence of this.

3 Link to overarching policy, and or procedure

Continence manual

4 Procedure or implementation

4.1 Symptoms of AD

Flushing.
Sweating and goose pimples.
Pounding headache.
Peripheral cyanosis.
Blurred vision and dizziness.
Shortness of breath.

Slow pulse staff must consider AD and assess for potential causes listed below, as early recognition of AD is essential in order that treatment can be initiated immediately.

4.2 Common causes

4.2.1 Bladder

Distended bladder.
A kink in the catheter.
An over-full leg bag.
Blockage or obstruction that prevents urine flowing from the bladder.
Urinary tract infection or bladder spasms.
Bladder stones.

4.2.2 Bowel

Distended bowel which can be due to a full rectum, constipation or impaction.
Any stimulation to the rectum including digital stimulation or digital removal of faeces.
Haemorrhoids.
Anal Fissures.
Stretching of rectum or anus or skin breakdown in the area.

4.2.3 Examples of other causes

Pressure sores.
Sexual activity.
Gynaecology-menstrual pain, labour and delivery.
Bone fractures below the level of the spinal cord injury.
Pain and trauma.
Acute conditions such as gastric ulcer.
Deep Vein Thrombosis.

Tight clothing, any noxious stimuli may trigger an autonomic response and therefore an AD event.

4.3 Treatment

If AD is suspected:

assist the patient to sit upright as soon as possible
record blood pressure (BP)
if the systolic BP is elevated ( greater than 150mmHg) it should be treated until the cause is found and eliminated
give Glyceryl tri-nitrate-(GNT) spray or nifedipine as prescribed

Once the cause has been addressed continue to monitor blood pressure. This must be monitored at least 2 hours after it has been stabilised.

4.3.1 Identify and remove the cause

4.3.1.1 Bladder

Do not attempt to administer a catheter maintenance solution as this could increase the blood pressure.

If the patient has an indwelling urethral or suprapubic catheter, check the following:

is the drainage bag full?
is the tubing kinked?
is the drainage bag at a higher level than the bladder?
is the catheter blocked? After correcting the obvious problem, and if the catheter is still not draining after 2 to 3 minutes, change the catheter immediately

4.3.1.2 Bowel

A digital rectal examination (DRE) is required to ascertain if the rectum is full and if so to remove the blockage. This is done by:

donning personal protective equipment (PPE)
inserting a gloved finger lubricated with an anaesthetic lubricant, such as 2% lignocaine gel (Instillagel) into the rectum
if the rectum is full insert additional lubricant
it is necessary to wait a minimum of 3 minutes to in order to reduce the sensation in the rectum. Not waiting for this length of time prior to performing digital stimulation (in order to trigger peristalsis) and DRF may worsen the AD
please refer to the Royal College of Nursing, bowel care leaflet for further information (opens in new window)

If AD symptoms develop whilst DRF is being undertaken the procedure must be stopped immediately and only resumed after the symptoms subside. If dysreflexia persists or no cause can be found, then an emergency medical assessment is required.

4.4 Prevention

Prevention is essential as most causes can be avoided by:

4.4.1 Bladder

Change catheter regularly to prevent blockage.
Keep catheters free of kinks, clean and ensure the intermittent catheterisation regime is followed to avoid an overfull bladder.
Check signs of infection, for example, urinary tract infection (UTI).
Have regular bladder and bowel check-ups with either the general practitioner (GP), community nurse or spinal injuries unit.
Drink enough fluids.

4.4.2 Bowel

Maintain a regular bowel management plan. If you have any concerns or queries about the bowel management plan, liaise with the spinal injuries or neurorehabilitation consultant involved with the patients care.
Adequate fibre intake to help avoid constipation.
Get treatment for haemorrhoids.

4.5 Autonomic Dysreflexia emergency kit

Ensure the patient has an AD kit available with them, this should contain:

catheter and supplies for catheterisation
medication prescribed for autonomic dysreflexia (Glyceryl tri-nitrate- (GNT) Spray or Nifedipine)
anaesthetic lubricant like 2% lidocaine gel
dressing pack, including sterile gloves and apron
wet wipes and disposable bag

5 References

Document control

Version: 2.
Unique reference number: 489.
Approved by: Clinical policy review and group.
Date approved: 1 February 2022.
Name of originator or author: Donna Atkinson.
Name of responsible individual: Team leader specialist continence service.
Date issued: 14 February 2022.
Review date: February 2025.
Target audience: All clinical staff.
Description of change: Expanded abbreviation of BP (now section 4.3), expanded GTN abbreviation (now section 4.3), expanded abbreviations and linked to the RCN bowel care leaflet, expanded UTI abbreviation (now section 4.4) expanded GP abbreviation (now section 4.4).

Page last reviewed: April 24, 2024
Next review due: April 24, 2025

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