Indian Journal of Palliative Care
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  In this Article
    Bladder Management
    Bowel Management
    Reflex bowel emp...
    Manual evacuation
    Autonomic Dysref...
    Bracing-Spinal c...
    References
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CLINICAL GUIDELINES
Year : 2003  |  Volume : 9  |  Issue : 1  |  Page : 14-18

Management of Paraplegia in Palliative Care


1 Dept of Physical Medicine and Rehabilitation, Christian Medical College Vellore 632004, India
2 Lecturer in Orthopaedics, India

Correspondence Address:
Suranjan Bhattacharjee
Dept of Physical Medicine and Rehabilitation, Christian Medical College Vellore 632004
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Bhattacharjee S, Poonnoose P. Management of Paraplegia in Palliative Care. Indian J Palliat Care 2003;9:14-8

How to cite this URL:
Bhattacharjee S, Poonnoose P. Management of Paraplegia in Palliative Care. Indian J Palliat Care [serial online] 2003 [cited 2020 Aug 11];9:14-8. Available from: http://www.jpalliativecare.com/text.asp?2003/9/1/14/19872


Explanatory notes


   Bladder Management Top
[1]

If survival is expected to be more than 2 months, consider teaching the patient or his attendant intermittent clean catheterisation (ICC) so that the patient can be catheter free. If urine dribbles in between the 4-6 hourly catheterisations, reduce fluid intake or start on appropriate medication. (Anticholinergics such as probanthin, oxybutinin or tolteridine if the lesion is suprasacral; or drugs with sympathetomimetic action such as imipramine, amitryptiline, or ephedrine if the lesion is at the cauda equina.) If ICC is not feasible or the patient is on chemotherapy and requires a high fluid intake continue with the indwelling catheter. This will need to be changed at regular intervals-once a week while in hospital and once in 3 weeks at home.


   Bowel Management Top
[2]

The sacral reflex arc is usually present is present in patients with lesions above T12. In such cases of a 'spastic bowel', reflex bowel emptying can be achieved by performing digital stimulation. Patients with lesions below T12 do not have reflex activity because the cauda equina is involved and need daily manual digital evacuation.


   Reflex bowel emptying Top


Ensure that the anal reflex is present. Insert 2 suppositories or a microenema deep into the rectum.. If the rectum is loaded with faeces an initial manual evacuation may need to be done before inserting the suppositories.

Leave the suppossitories in for 30-60 minutes; if the reflex is strong enough some faeces will be expelled. Then perform digital stimulation. Insert one gloved and lubricated finger into the rectum and rotate it 3-4 times in a clockwise manner. Withdraw the finger and wait for 10 minutes. If no reflex evacuation occurs, repeat the procedure. Three to four such periods of stimulation should empty the rectum.


   Manual evacuation Top


Gently rotate a single gloved, lubricated finger within the rectum, and draw the faeces backwards and out of the anal canal taking care not to injure the bowel wall. If the faeces are very hard and dry, use 2 glycerine suppositories or a microenema 30 minutes before the procedure. If the faeces are not formed, leave for another 24 hours. A bulking agent may be helpful in patients who are not on opioids


   Autonomic Dysreflexia Top


Autonomic dysreflexia can occur in patients with lesions above T7 and presents with pounding headaches, profuse sweating, nasal stuffiness, and a flushed face. Without prompt intervention intracranial bleeds may occur. Autonomic dysreflexia is precipitated by a distended bladder caused by a blocked catheter, constipation, anal fissures, or bladder stones. The nociceptive stimulus causes sympathetic overactivity below the level of the lesion resulting in vasoconstriction and hypertension. Hypertension stimulates the carotid and aortic baroreceptors leading to parasympathetic overactivity above the level of the lesion.

Treatment-Remove the precipitating factor e.g-change the blocked catheter. Sit the patient up. Administer nifedipine 5-10mg sublingually or GTN spray 200-400 micrograms sublingually. Phentolamine may be needed in refractory cases.


   Bracing-Spinal columns Top


The 3 column theory (Denis 1983) is used to assess the stability of the damaged thoracolumbar spine. The anterior column contains the anterior longitudinal ligament, the anterior half of the vertebral body, and the anterior portion of the annulus fibrosus. The middle column consists of the posterior longitudinal ligament, the posterior half of the vertebral body, and the posterior aspect of the annulus fibrosus. The posterior column includes the neural arch, the ligamentum flavum, the facet capsules, and the interspinous ligaments. Involvement of 2 or more columns results in an unstable spine.

*.Cancer anorexia and cachexia may make it difficult to improve nutritional status in many patients. Recommendations to improve nutrition should not be made indiscriminately.



 
   References Top

1.Denis F.,1983: The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine. Nov-Dec;8(8):817-31.  Back to cited text no. 1    
2.Harrison P (2000): Bowel management after spinal cord injury. In: Managing Spinal Injury: Critical Care, London, Spinal Injuries Association, p82.  Back to cited text no. 2    


    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]



 

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