Professional Documents
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Complications
Complications
Management of
Address correspondence to
Dr Carolin I. Dohle, Burke
Rehabilitation Center, 785
Mamaroneck Avenue,
White Plains, NY 10605,
carolin.dohle@gmail.com.
Relationship Disclosure:
Medical Complications
Dr Dohle and Dr Reding Carolin I. Dohle, MD; Michael J. Reding, MD
report no disclosure.
Unlabeled Use of
Products/Investigational
Use Disclosure: Dr Dohle ABSTRACT
and Dr Reding report no
disclosure.
Medical comorbidities and complications are expected following stroke, traumatic brain
Copyright * 2011, injury, and spinal cord injury. The neurorehabilitation physician’s role is to manage these
American Academy of comorbidities, prevent complications, and serve as a medical and neurologic resource for
Neurology. All rights the patient, family, and neurorehabilitation team. The most common comorbidities are
reserved.
similar to those found in the general population, namely hypertension, dyslipidemia,
diabetes mellitus, and ischemic heart disease. Frequent complications encountered in the
neurorehabilitation unit relate to medication side effects, medical comorbidities, and the
direct effect of the neurologic injury. They include orthostatic hypotension; syncope or
presyncope; cardiac arrhythmia; bowel and bladder dysfunction; seizures; pressure sores;
dysphagia-related pneumonia, dehydration, and malnutrition; venous thromboembo-
lism; falls; and sexual dysfunction. This article discusses strategies for managing comor-
bidities and avoiding complications.
KEY POINTS
h Euglycemia is the that the better the blood glucose regu- ened liquid several times per day will help
goal of diabetes lation the better the functional out- supplement hydration. It is difficult to
management but come. However, a number of special maintain adequate hydration for those on
must be balanced issues interfere with diabetic manage- honey-thick liquids. It is important to note
with the risk of ment following neurologic injury: inabil- that diuretics are used to enhance renal
hypoglycemia in ity to express hypoglycemic symptoms sodium excretion. Extracellular water vol-
patients unaware because of aphasia, altered awareness of ume decreases as a result of enhanced
of or unable to impending hypoglycemia, dysphagia- renal sodium clearance. Coupling a di-
express symptoms of related variability in food intake, and uretic with adequate hydration is neces-
hypoglycemia. meals and exercise that are regulated by sary to ensure adequate renal function.
h Daily physician the patient’s schedule and not by the On daily rounds the physician can observe
assessment of patient. Blood glucose is frequently dif- the patient’s resting respiratory rate while
congestive heart ficult to control when the patient is on the patient is in a comfortable position
failure signs and tube feedings, and the timing of moni- in bed or in a wheelchair. Auscultation of
symptoms plus periodic
toring and insulin administration should the lungs with detection of basilar rales,
$-natriuretic peptide,
be adjusted. The goal is to balance the dullness to percussion over the lung bases,
blood urea nitrogen/
creatinine, electrolyte,
need for near-normal blood glucose presence or absence of jugular venous
and chest x-ray provide levels with avoidance of symptomatic distension (more than 12 cm above the
guidance in managing hypoglycemia. Because glycosylated sternomanubrial joint is abnormal in
cardiac response to hemoglobin levels change slowly, we either supine or sitting position), and
progressive self-care have not found them to be a useful presence of either bilateral pedal or pre-
and mobility exercises. guide for diabetic management during sacral edema are all indicators of CHF.
the several-week inpatient neurorehabil- Daily observation for the presence of
itation stay. Fingerstick blood glucose these signs of CHF should trigger further
determinations before meals and at bed- evaluations such as serum $-natriuretic
time remain the most valid assessment of peptide (BNP) assessment. BNP is a re-
diabetic management. liable marker of atrial stretch response
to intravascular volume expansion un-
Congestive Heart Failure less significant renal dysfunction is pres-
American Heart Association standards ent. In the presence of chronic kidney
for managing congestive heart failure disease with serum creatinine greater
(CHF) advocate use of three classes of than 2.0 mg/dL, the BNP may not accu-
medication: a diuretic, a beta-blocker, rately reflect CHF status. A follow-up
and an angiotensin-converting enzyme chest x-ray can confirm the clinical assess-
inhibitor or angiotensin receptor blocker.3 ment. Follow-up echocardiograms are
Use of these standard medications may not usually available on the neuroreha-
have to be modified during neuroreha- bilitation unit. With daily physician assess-
bilitation because of dysphagia-related ments and appropriately timed serum
dehydration, diabetic or vascular renal BNP, blood urea nitrogen (BUN), serum
insufficiency with hyperkalemia, and bra- creatinine, and serum electrolyte assess-
dycardia or OH. Daily rounds by the ments it is usually possible to titrate the
physician are important for adjusting dos- patient’s CHF medications to optimize
ages of CHF medications. Patients with functional status and avoid dehydration.
dysphagia may not be able to tolerate the
use of diuretic medications. They may PREVENTION OF COMMON
report that they do not like the taste of COMPLICATIONS
thickened liquids and hence cannot main- Cardiovascular Complications
tain adequate oral hydration if given a Orthostatic Hypotension. OH is
diuretic. Frequent small amounts of thick- defined by the American Academy of
Case 6-1
A 74-year-old man with a history of left basal ganglia infarct resulting in right hemiparesis and dysarthria
was admitted to the neurorehabilitation unit. Review of his hospital chart revealed that the patient had a
history of uncontrolled hypertension, coronary artery disease, diabetes mellitus, and hyperlipidemia. During
his acute hospitalization he had frequent blood pressure spikes with systolic blood pressure recordings of up
to 200. He was being treated with hydralazine, metoprolol, and lisinopril and was on a pureed diet and
nectar-thick liquids because of dysphagia. On his second day of admission, the patient began physical
therapy. He was ambulating 10 feet with moderate assistance at the hemibar when he suddenly became
diaphoretic and weak and reported dizziness. He was immediately placed in a reclining wheelchair and
brought back to his room. His heart rate was 90 beats/min, his blood pressure was 90/68 mm Hg, his oxygen
saturation was 96% breathing room air, and his blood sugar was 114. His morning laboratory results
showed a serum sodium of 147, a blood urea nitrogen of 35, and a creatinine of 1.0. The patient appeared
lethargic. He was placed in Trendelenburg position, and over the next 20 minutes his mental status slowly
returned to baseline. His medications were reviewed and a decision was made to stop his hydralazine.
Because of his history of diabetes and coronary artery disease, the lisinopril and metoprolol were reduced in
dose but not stopped. Orders were given to obtain blood pressure measurements with the patient sitting up
to avoid falsely high readings. Orders were also written to give 3 ounces of nectar-thick fluids with each
therapy session to improve hydration. Elastic wraps and an abdominal binder were applied to further provide
circulatory support. The patient was allowed to return to his therapy sessions after his symptoms subsided.
Comment. This case illustrates that even patients with baseline hypertension and high blood pressure
readings when supine may suffer from orthostatic hypotension when standing or sitting up in a chair.
The doses of blood pressure medications need to be decreased, with an emphasis on those that do not
benefit other medical conditions the patient has. Blood pressure readings for this patient should be
taken in a sitting position. Because he has dysphagia and is taking nectar-thick liquids (which he does not
like), he is having trouble maintaining adequate hydration.
another stimulus to the sacral, lumbar, seated rather than supine position may
or thoracic spinal cord often triggers an be of immediate benefit. Using lido-
AD episode. Placing the patient in a caine gel to ease noxious stimuli asso-
ciated with bladder catheterization or
digital disimpaction may terminate the
episode. The Consortium for Spinal
Cord Medicine clinical practice guide-
lines acknowledge that no randomized
controlled trials to identify optimal med-
ical management of AD have been
reported.13 Reasonable alternatives are
oral nifedipine, hydralazine, prazosin,
captopril, and transdermal nitrate. In
severe persistent episodes, IV nitro-
prusside in an emergency department
or intensive care unit setting may be
required for patient stabilization. Use of
FIGURE 6-1 Tilt-in-space wheelchair. These wheelchairs sildenafil for erectile dysfunction within
may be beneficial for patients with
orthostatic hypotension, poor head or trunk 24 hours is a relative contraindication
control, and decreased endurance, and can help relieve pain for use of nitrates.
from pressure ulcers through weight shifting. The angle Syncope or Presyncope. If a clear
between the seat and wheelchair back remains constant
when the patient is tilted back. orthostatic association with syncope or
presyncope exists, the etiology of the
KEY POINT
h Routine seizure incidence of clinical seizures following Risk factors include compressive
prophylaxis is not intracerebral hemorrhage (ICH) has forces and shearing forces.21 Compres-
recommended for been reported to be 14%, with most sive forces are directed perpendicular to
patients with stroke occurring at or shortly after the acute the skin surface, whereas shearing forces
or intracerebral event.14 Electroencephalographic evi- are exerted parallel to the skin surface.
hemorrhage. dence of seizure activity may be as high Shearing forces depend on the position
as 28% to 31% in patients with ICH of the patient. The shear exists between
having continuous EEG monitoring. No the different layers of the fascia. The in-
clear evidence exists for prophylactic fluence of body weight on shearing and
use of anticonvulsants to improve func- compressive forces is such that in
tional outcome or survival. Patients with patients with cachexia higher peak pres-
ischemic stroke or ICH who have clini- sures exist than in larger persons, in
cally apparent seizures and patients whom the pressure is dispersed through-
with electroencephalographic evidence out a larger surface area.22 The duration
of seizures with accompanying change of pressure has been found to be an
in mental status should be given anticon- independent risk factor, and the fre-
vulsants. Evidence from animal studies quency of turning the patient has been
suggests that phenobarbital, topiramate, linked to the incidence of pressure
lamotrigine, and phenytoin may impair ulcers.23 The risk of developing pressure
motor recovery15; however, clinical evi- sores is further increased in patients with
dence is still lacking. decreased sensitivity to pain from the
pressure and those who have decreased
Pressure Sores ability to shift their weight in order to
Pressure sores are defined as wounds reduce the pressure.
resulting from pressure or friction on Poor nutrition is an independent risk
any part of the body. Immobilized neu- factor for pressure sores. Low albumin
rorehabilitation patients in hospital levels have been associated with a higher
and nursing home settings following risk of developing these lesions. Indi-
stroke or SCI are at high risk of devel- viduals who are malnourished have a
oping pressure sores. Pressure sores twofold to threefold higher risk of devel-
can cause pain, increase disability, and oping ulcers than patients with normal
lead to systemic infections and death.16 nutritional status, and providing individ-
The incidence of pressure sores is es- uals with nutritional supplements has
timated to be 25% to 30% in patients been shown to accelerate healing.24 Pa-
with SCI17,18 and 20% in patients with tients with albumin levels of less than
stroke.19,20 3.5 have been shown to have a greater
Pressure ulcers develop when the risk of developing ulcers and slower ul-
pressure on the tissue is persistently cer healing.25
greater than the capillary pressure, which Pressure ulcers develop over bony
has been traditionally quoted to be protrusions. A study involving patients
32 mm Hg, for more than 2 hours.21 with SCI found that the ischial tuber-
However, newer studies have shown that osities, sacrum, greater trochanters, lat-
with increasing external pressure the ar- eral malleoli, and heels are commonly
teriolar pressure increases through auto- affected.26 Shear forces and inconti-
regulation unless the external pressure nence with skin maceration further
exceeds the diastolic pressure. At this traumatize the skin and facilitate bacte-
point, a significant decrease in tissue oxy- rial and fungal infections.
gen partial pressure (PO2) occurs with The Braden scale and the Norton
resulting tissue hypoxia and necrosis. scale are used to identify patients at
Dysphagia-Related Complications
Dysphagia and its management are dis-
cussed in detail in the article ‘‘Treatment
of Language, Motor Speech Impairments,
and Dysphagia.’’ The most important
medical complications of dysphagia are
pneumonia, dehydration, malnutrition,
unreliable medication intake, and upper
airway obstruction.
A bedside evaluation of swallowing
should be conducted prior to initiation
of oral intake of food or liquids following
stroke or TBI.29 Based on the bedside
dysphagia evaluation, patients at risk for
aspiration can be given nectar- or honey-
consistency liquids. Patients deemed
unsafe for oral feeding require naso-
gastric feeding tube placement. Naso-
gastric tubes are poorly tolerated by
patients and proper positioning must
be checked by air bolus auscultation
over the abdomen prior to each feed-
ing. If a nasogastric tube is required
for more than 1 or 2 weeks a percuta-
neous endoscopic gastrostomy (PEG)
tube should be placed.
Patients with dysphagia significant
FIGURE 6-3 Wheelchair cushions. A, gel wheelchair enough to require thickened liquids
cushions distribute body weight over the area
of the entire cushion, reducing pressure. are at risk for recurrent aspiration of
However, they may be quite heavy, do not absorb shocks as well saliva and other thin liquids between
as other cushions, and have the potential of leaking. B, foam
wheelchair cushions are light and usually easy to maintain. meals and at night. Using an oral swab
Several density-graded foams can be used in one cushion to to cleanse the teeth, tongue, and buc-
provide different amounts of support for different skin areas;
however, the foam may lose its shape over time. C, air-inflated colabial folds after meals can help de-
wheelchair cushions are composed of an array of small crease the amount of bacterial and
interconnected air bladders. Individual air bladders can be tied particulate material available for aspira-
off to customize pressure points. These cushions may provide
less stability and are potentially difficult to clean. tion. Use of incentive spirometry, nebu-
lized bronchodilator treatments, and
Case 6-2
A 36-year-old man was admitted to the spinal cord unit 2 weeks after a motorcycle accident. He had
sustained multiple bone fractures, liver and spleen lacerations, and a T8 spinal cord transection. On
examination, the nurse noticed a 4 cm diameter erythematous area over his sacrum that did not blanch
when touched. In the center, a 2 cm diameter shallow ulcer was present. The base of the ulcer was pink
and clean with hair follicles visible. The wound was classified as a stage II pressure ulcer. It was gently
cleaned with normal saline, and a silver impregnated sodium carboxymethylcellulose dressing was
applied. The patient was frequently turned, and pressure on his sacral area was minimized using an
alternating pressure air mattress. While sitting in a wheelchair, he was supported with a gel-based
wheelchair cushion. His wheelchair was placed in a reclining position at regular intervals during the day to
further alleviate any pressure points. The patient’s albumin level was 2.8, so he was started on a
multivitamin, vitamin C, and a protein-enriched diet. With the above measures, his ulcer slowly improved.
Comment. This case illustrates the importance of aggressive management of pressure ulcers. Management
includes wound care, patient positioning, alleviation of pressure points, and nutritional support.
to water, such as with the Frazier Rehab and medication administration, a PEG
Institute Free Water Protocol (permit- tube should be considered. Having nurs-
ting small sips of water between meals ing staff estimate the amount of food on
with nursing staff providing oral and the diet tray that is consumed provides a
dental hygiene following each meal), reasonable approximation of total calo-
may be appropriate.31 This allows pa- rie consumption. Patients and families
tients to safely consume small volumes may reject discussions of PEG placement
of thin liquids and improves hydration. because they perceive it as artificially pro-
Diuretics should be stopped unless longing life. However, case-matched con-
needed for management of active CHF. trolled studies have shown that patients
To ensure adequate hydration, it is rea- given PEG tube feedings do as well as
sonable to request that patients receive equally severely impaired patients who
at least 3 ounces of thickened liquid with do not need PEG feeding.32 They have
each therapy session. Renal and electro- similar Functional Independence Mea-
lyte checks can be used to follow the sure efficiency values and are equally
patient’s response. If necessary, a nurs- likely to return to their home. PEG feed-
ing order can be written to give the pa- ings allow patients who are effectively
tient 250 mL of thickened liquid as a starving to show significant functional re-
medication every 4 to 6 hours while covery. Most will not need their PEG
awake. Supplemental IV hydration may tube for more than 4 to 10 weeks, and
also be needed. It is common to monitor most PEG tubes can be easily removed
the BUN/creatinine ratio, with values by traction or balloon deflation on the
greater than 20 indicating prerenal neurorehabilitation unit or in the office.
azotemia due to dehydration. Patients To prevent spilling of gastric content
with dysphagia may be sufficiently mal- to the peritoneum, PEG tubes should
nourished so as to show only mildly remain in place for at least 2 weeks
elevated BUN/creatinine ratios because prior to removal, with some recom-
of dietary protein depletion. Such pa- mending up to 6 weeks.
tients may have elevated serum so-
dium values in the 150 range, serving Deep Vein Thrombosis
as a reliable secondary marker for sig- In patients admitted to a rehabilitation
nificant dehydration. hospital and in patients within 21 days of
Malnutrition due to dysphagia and in- stroke onset, the prevalence of deep vein
adequate calorie intake can be followed thrombosis (DVT) has been reported to
using body weight, but values fluctuate be 34% to 40.2% and even as high as
and change slowly. Urinary ketones may 50%.33 The prevalence of DVT in patients
be detectable after a 24-hour fast. Use with TBI has been reported to be 11%.34
of urinary ketone levels as a marker for Most of these patients were asymptom-
inadequate calorie intake is valid even in atic.35 Higher incidences seem to be re-
patients with diabetes as long as no glyco- lated to greater severity of weakness.36
suria is present. Serum prealbumin levels DVTs usually occur in the paretic leg.
fall much earlier than serum albumin or It is important to be vigilant for the
total serum protein levels and are the best development of DVT in the neurore-
marker for inadequate protein intake. habilitation population because clinical
All patients on an altered-consistency diet signs may not be present in these pa-
should be assessed for the need for die- tients owing to sensory loss and the
tary supplements and multivitamins. inability to report symptoms because
If the above measures are not effec- of cognitive or language impairment.
tive in maintaining hydration, nutrition, Screening tools should be cost-efficient,
KEY POINT
h Chronic constipation is presence of active bleeding, heparin- bowel movement occurs is reasonable.
expected in immobilized induced thrombocytopenia, or other Manual insertion of the suppository ini-
patients and can disorders affecting blood clotting. Foot, tiates the anal-colon defecation reflex.
be prevented. calf, and sequential calf-thigh compres- Bisacodyl also has a direct effect on the
sion pump systems are available. smooth muscle of the colon, stimulating
Sequential calf-thigh systems provide colonic emptying. Additional strategies
optimal prophylaxis but are poorly such as enemas or lactulose may be
tolerated because of discomfort and needed. Lactulose can produce loose
interruption of sleep. Foot-pump sys- stools in any individual if given in higher
tems are tolerated the best but are not doses. Lactulose is not absorbed and is
as effective as either calf or sequential without systemic toxicity. Polyethylene
calf-thigh applications.46 Rapid com- glycol compounds (eg, Miralax) may also
pression of the venous plexus in the be helpful. However, if a patient cannot
instep of the foot is able to produce a move his or her bowels for several days,
100 mm Hg plethysmographically the possibility of an obstruction must be
detectable pulse wave in calf veins. ruled out.
The pulse wave is thought to provide Urinary incontinence (UI) or uri-
venous pulse pressures similar to step- nary retention affects a large percent-
ping and weight bearing during the age of patients with acquired brain or
gait cycle; however, these devices are spinal cord injury. The prevalence of
not frequently used or not used UI after stroke has been reported as
correctly. almost 50% (including complete and
incomplete UI).47 However, this prev-
Bowel and Bladder Dysfunction alence is linked to the severity of
Colonic stasis is expected as a result of neurologic injury. Only 5% of patients
immobility of any cause. A high-fiber with pure motor strokes are expected
diet containing 35 grams of fiber plus a to have UI,48 while approximately 75% of
stool softener such as docusate sodium patients with motor, hemisensory, and
100 mg 3 times daily is an initial pro- hemianopic neurologic impairments are
phylactic option. Use of bisacodyl sup- expected to experience UI during the
positories daily or every other day if no first month following stroke. Case 6-3
Case 6-3
A 78-year-old woman with recent infarct involving the left temporal-parietal cortex had resulting global
aphasia and right hemiparesis. On the second day of her admission to the inpatient rehabilitation unit,
the physical therapist noticed that she seemed less alert than on the day of admission and that she
appeared uncomfortable. She was afebrile. Discussion with nursing staff revealed that the patient had
not voided over the past 8 hours. On physical examination, dullness to percussion over the suprapubic
region was present. Bladder scan showed a postvoid residual volume (PVR) of 700 mL. Intermittent
catheterization was initiated, and urine analysis and urine culture were obtained. PVR assessments were
ordered every 6 hours with instructions to perform intermittent catheterization for a PVR volume greater
than 250 mL. Additionally, she was started on tamsulosin for internal urethral sphincter relaxation.
Ciprofloxacin was started subsequently when her urine analysis showed significant pyuria.
Comment. This case illustrates that it is necessary to be vigilant for stroke complications such as
urinary retention because patients often cannot report specific symptoms because of their neurologic
dysfunction. Careful assessment of the patient’s voiding status and frequency of bowel movements
must be made to avoid obstructive uropathy and fecal impactions. Urinary retention is treated with
intermittent catheterization rather than an indwelling catheter.
KEY POINTS
h Intermittent bladder with neurologic impairments who are mixed results. The prophylactic use of
catheterization is unable to participate in the procedure. antibiotics carries the risk of selecting
preferable to Such patients may need external con- for resistant organisms and is not rec-
indwelling catheter dom specimens (males) or catheterized ommended. Urinary tract antiseptics
for management of urine specimens (females). Contami- such as methenamine mandelate and
urinary retention. nation of the urine specimen by vagi- methenamine hippurate, which are con-
h Time-prompted nal or perineal mucus frequently gives centrated in the urine and metabolized
voiding schedules rise to artifact in laboratory analysis to formaldehyde in an acidic urine, are
can ameliorate of pyuria and bacteriuria. Early recog- bactericidal for all organisms and may
urge incontinence. nition and treatment of UTI may pre- have a limited role in the prevention of
vent development of symptomatic in- recurrent UTIs in selected patients re-
fections or urosepsis which can impede quiring indwelling Foley or suprapubic
stroke recovery and prolong the hospi- catheters.
tal stay.51 Time-prompted voiding schedules
Urinary retention is an indepen- 30 minutes after meals and every 2
dent risk factor for UTI,52 and if it is hours between meals while awake can
severe enough it may lead to renal in- decrease urge incontinence. Kegel ex-
sufficiency and renal failure. Indwelling ercises are appropriate for women
Foley catheters are one means of treat- with comorbid stress incontinence but
ing urinary retention. They have, how- have limited use in patients with neu-
ever, been shown to significantly in- rologic injury. Condom catheters are
crease the risk of developing a UTI.53 useful for symptomatic management
Intermittent catheterization based on of urge incontinence in men without uri-
bladder ultrasound determinations every nary retention.
6 hours is associated with a signifi- Pharmacologic treatment of urinary
cant decrease in UTIs. The risk of in- retention due to internal urethral sphinc-
ducing infection versus the need to ter disinhibition can be initiated with !1
prevent bladder distension is probably receptor antagonists, which exert their
optimized by requesting that the pa- action specifically on !1A receptors in
tient be catheterized when postvoid the prostatic urethra and the vesi-
residual volume by Doppler determi- courethral junction. Such medications
nations is in excess of 350 mL. This is have also shown benefit in women
based on the observation that the nor- with urinary retention due to stroke,
mal upper limit of bladder volume is TBI, or SCI.54 They are also useful in
500 mL for women and 700 mL for men. men with coexisting prostatic hyper-
Indwelling Foley catheters should be re- trophy. Urecholine may be helpful in
served for patients for whom intermit- stimulating detrusor contractility but is
tent catheterization is difficult because relatively contraindicated in patients
of their size, presence of urethral trauma, with cardiac disease.
infected sacral sores made worse by in- Drugs with anticholinergic and anti-
continence, or behavioral issues. Anti- muscarinic effects, such as oxybutynin
septic Foley catheters as well as cathe- and solifenacin, are often used to treat
ters coated with antibiotics suitable for urge incontinence. They have limited
chronic use have been examined; how- ability to cross the intact blood-brain
ever, no good evidence exists regard- barrier; however, they should be used
ing their efficacy in preventing UTIs. with caution in patients with strokes
Studies examining prophylactic treat- or other CNS disorders that can inter-
ment with antibiotics in patients with fere with the blood-brain barrier be-
indwelling Foley catheters have shown cause they may potentially interfere
KEY POINT
when he or she is out of bed, wheel- Radiology and Intervention Council;
h A risk-benefit Atherosclerotic Peripheral Vascular Disease
assessment of chair lap belts, and enclosed bed sys- and Quality of Care Outcomes in Research
fall prevention tems offer graded interventions to Interdisciplinary Working Groups.
strategies should reduce falls. These safety interventions Guidelines for the early management of
adults with ischemic stroke: a guideline
consider patient may not be tolerated by some patients from the American Heart Association/
acceptance or rejection and actually increase their risk of fall- American Stroke Association Stroke
of their use. ing if they cause agitation or the patient Council, Clinical Cardiology Council,
struggles against them. Moving the pa- Cardiovascular Radiology and Intervention
Council, and the Atherosclerotic Peripheral
tient to a private room and having a Vascular Disease and Quality of Care
family member stay with the patient Outcomes in Research Interdisciplinary
is sometimes feasible. Providing indi- Working Groups. Stroke
2007;38(5):1655Y1711.
vidual patient supervision is costly but
should be provided if other measures 3. Jessup M, Abraham WT, Casey DE, et al.
2009 focused update: ACCF/AHA Guidelines
fail. Psychiatric consultation may be re- for the Diagnosis and Management of
quested when pharmacologic interven- Heart Failure in Adults: a report of the
tion is required to ensure patient safety. American College of Cardiology
Foundation/American Heart Association
Many neurorehabilitation physicians are Task Force on Practice Guidelines:
experienced in the use of psychoactive developed in collaboration with the
medications and manage patients who International Society for Heart and Lung
are agitated or confused without psy- Transplantation. Circulation 2009;119(14):
1977Y2016.
chiatric consultation.
4. The Consensus Committee of the
Special undergarments with impact- American Autonomic Society and the
absorbing pads over the greater tro- American Academy of Neurology.
chanters may reduce the risk of frac- Consensus statement on the definition of
tures.57 Patient compliance with their orthostatic hypotension, pure autonomic
failure, and multiple system atrophy.
use is poor because of their bulky ap- Neurology 1996;46(5):1470.
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them on and off while toileting. spinal shock? Arch Neurol 1999;56(8):
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phonates in patients following stroke to 6. Krassioukov AV, Furlan JC, Fehlings MG.
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cord injury: an under-recognized clinical
are also commonly prescribed following entity. J Neurotrauma 2003;20(8):
SCI and in patients with severe TBI and 707Y716.
limited mobility. Use of a calcium sup- 7. Kirshblum SC, House JG, O’Connor KC.
plement with vitamin D is also reason- Silent autonomic dysreflexia during a
able for such patients.59 routine bowel program in persons with
traumatic spinal cord injury: a preliminary
study. Arch Phys Med Rehabil 2002;
83(12):1774Y1776.
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