Troubleshooting

Autonomic dysreflexia is an abnormal, widespread overactivity of the involuntary (autonomic) nervous system to stimulation, which is uncontrolled and if not promptly treated can be life threatening.⁴

Signs and symptoms

Sudden hypertension; pounding headache; bradycardia; flushing or blotching of skin above SCI level; profuse sweating above SCI level; skin pallor and piloerection below SCI level; chills without fever; nasal congestion; blurred vision; shortness of breath; sense of apprehension or anxiety.

Possible cause

• Any irritating (nociceptive) stimulus below the level of SCI can trigger excessive reflex activity of sympathetic nervous system and secondary parasympathetic activity
• Constipation
• Rectal prolapse (when the rectum protrudes from the anus), caused by high volume enemas, digital stimulation and removal
• Enlarged haemorrhoids
• Irritation from enema

Recommendation

• Autonomic dysreflexia during bowel care is usually temporary and resolves without lasting effects. If signs and symptoms occur, reduce digital stimulation
• Review bowel care techniques
• Prevent constipation, e.g. through dietary considerations and fluid intake
• Consider using topical anaesthetic gel (2% lignocaine) inserted into the rectum 5 minutes prior to digital stimulation and manual evacuation

Bristol stool type: ≥6

Possible cause

• Excess fluid intake
• Alcohol intake can affect consistency of the stool
• Medications (especially antibiotics)
• Diet, e.g. poor soluble fibre intake, fatty or spicy foods, and caffeine may cause diarrhoea
• Gastrointestinal illness

Recommendation

• Review fluid and dietary fibre intake
• Review medications and aperients. Stool softener dosage is individual and too much can often be a problem
• Consider adding or increasing bulking agents
• Use a food diary to record foods and the outcomes of stool consistency
• Consider stool culture and clostridium difficile (a type of bacteria) if recently on antibiotics
• If unresolved, seek medical review

Notes

Review stool softener dosage before increasing fibre or bulking agents. This should be done gradually to allow the bowel to adjust, which will in turn prevent bloating and intestinal wind and gas.

Bristol stool type: 1

Possible cause

• Poor fluid intake (<1.5L)
• Caffeine and alcohol may have a diuretic action
• Excess insensible fluid loss (perspiration and vomiting)
• Low insoluble fibre diet
• Insufficient stool softeners
• Over-use of bulking agents
• Medication side-effects

Recommendation

• Increase fluid intake (>2L per day)
• Increasing insoluble fibre in diet will improve the consistency of stools
• Increase softeners and stimulants or decrease bulking agents
• Review and rationalise medications, e.g. narcotic analgesics, iron, and anticholinergics
• Review the frequency of bowel care if less than daily

Notes

• If fibre is increased in the diet then fluid intake should also be increased
• Stool softeners and stimulants should be taken at the same time each day in order to ensure maximum effect at the desired time. Stimulants should be taken 8-12 hours before bowel care

Possible cause

• Irregular bowel regimen
• High impaction with spurious (overflow) diarrhoea
• Bowel pattern may be changing

Recommendation

• Abdominal X-ray may help to confirm diagnosis
• In addition to the recommendations for constipation (above), ensure aperients are taken on a regular basis, i.e. twice per day
• Start a bowel chart and review if bowel routine is inadequate

Possible cause

• Insufficient time for bowel care or insufficient evacuation
• Stool too soft
• Certain irritant enemas or suppositories can cause incontinence or residue later in the day
• Change in diet
• Excessive digital stimulation can overstimulate the large bowel causing it to secrete mucous and contract causing incontinence
• Over-use of aperients
• Food poisoning or gastroenteritis

Recommendation

• Allow sufficient time for bowel care
• Review carer’s bowel management practices
• Review aperients and enema or suppository use
• Consider the use of an anal plug (for flaccid bowels)*
• Seek medical review if gastroenteritis is suspected

Notes

* The use of anal plug may cause autonomic dysreflexia, so should be used with caution.

Possible cause

Exacerbated by manual procedures (digital stimulation and digital removal of faeces), enemas and constipation.

Recommendation

Review rectal stimulant.