Autonomic dysreflexia in PACU

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I'm a new PACU nurse; I've only been only the floor for about 2 months. (Although I have several years of MedSurg experience.) I had a quadriplegic patient yesterday who seemed to be going into autonomic dysreflexia after he had a Baclofen pump implanted. He had a high systolic with a sky-high diastolic immediately upon arrival to the unit. Never having seen it myself, I only remembered about autonomic dysreflexia from years ago when I was in nursing school. The CRNA agreed with me that he thought that's what it was, and our anesthesiologist was quick to treat with an order for hydralazine; he also came and assessed the patient himself as soon as he was free. I was grateful that the pressures resolved within a short while. But i was wondering if anyone else has dsalt with this and if there were additional things I should assess for with autonomic dysreflexia other than BP in quadriplegic patients.

offlabel

1,466 Posts

A foley catheterization can set it off. Doesn't take much in some folks and they don't need a history of it to present. Profuse diaphoresis might be the only obvious sign before you get a blood pressure.

HeySis, BSN, RN

435 Posts

Specializes in PACU. Has 25 years experience.
A foley catheterization can set it off.

And a full bladder can set it off too... so can bowel issues....

Other symptoms you can notice are anxiety, increased heart rate, pounding headache.... sometimes those are very hard in PACU because they are common... but if your patient has a spinal cord injury at or above T6, then these symptoms need extra attention.