TEST FOR AUTONOMIC

NEUROPATHY
Dr.SRINIDHI
POST GRADUATE
DEPARTMENT OF ANAESTHESIOLOGY
GTMCH
Diabetic Autonomic Neuropathy
Vagus nerve (~75% of all parasympathetic activity),
earliest nerve
Effects are widespread but symptoms may be related to
single system
Systems
 Cardiovascular

 Gastrointestinal

 Genitourinary

 Adrenomedullary

 Peripheral vasomotor & sudomotor

 Pupillary
Cardiovascular autonomic neuropathy
Heart Rate changes
Impaired Heart rate variability
Resting tachycardia and fixed HR
BP changes
Nocturnal hypertension
Orthostatic hypotension
postprandial hypotension
Limited exercise tolerance
Silent myocardial ischemia
Diabetic cardiomyopathy
HR response to Respiration
The variation of heart rate with respiration is known as
Respiratory Sinus Arrhythmia (RSA
 Inspiration increases the heart rate
Expiration decreases the heart rate
This is an index of vagal control of heart rate
MECHANISMS
Influence of respiratory centre on the vagal control of heart
rate
Influence of pulmonary stretch receptors on the vagal
control of heart rate
PROCEDURE
Patient lies quietly and breathes deeply at a rate of six
breaths per minute and ECG is recorded. The difference
between the maximum and minimum heart rate and
Expiration to Inspiration (E:I) R-R interval ratio are
calculated.
Normal > 15 beats/min
Borderline = 11-14 beats/min
Abnormal < 10 beats/min
Determine the expiration to inspiration ratio (E:I ratio)
Mean of the maximum R-R intervals during deep
expiration to the mean of minimum R-R intervals during
deep inspiration
 Ratio = Longest RR interval (expiration)
shortest RR interval (inspiration)
E:I ratio is >1.17 are abnormal.
HR response to posture
 An immediate response with an abrupt fall in systolic and
diastolic blood pressure and a visible acceleration of heart
rate (first 30 s),
phase of early stabilization, which occurs after
approximately 1-2 min,
during the phase of stabilization , acceleration of heart
rate by about 10-15 beats per minute and a slight decrease
in systolic blood pressure, while diastolic pressure
increases by approximately 10 mmHg
PROCEDURE
ECG is recorded in lying followed by full upright
position. The R-R interval is measured at beats 15 and 30
after the patient stands.

On standing the heart rate increases until it reaches a

maximum at about 15th beat (shortest R-R interval after
standing)
after which it slows down to a stable state at about 30th
beat (longest R-R interval after standing)
A 30:15 ratio of < 1.03 is abnormal
Valsalva maneuver
Assesses integrity of the baroreceptor reflex
 Measure of parasympathetic and sympathetic function
 It is “forced expiration against a closed glottis”
There are 4 phases during this maneuver. The longest and
shortest R-R intervals are measured. The ratio is called
valsalva ratio.
The patient forcibly exhales into the mouthpiece of a
manometer, exerting a pressure of 40 mm Hg for 15
seconds.
Phase I – Onset of straining
Transient increase in BP which lasts for a few seconds.
HR does not change much.
Mechanism: increased intrathoracic pressure and
mechanical compression of aorta due to the act of blowing
Phase II - Phase of straining
Reduced venous return to right atrium- cardiac output and
systolic pressure .
Reflex tachycardia and peripheral vasoconstriction
Phase III - Release of straining
Transient decrease in BP lasting for a few seconds Little
change in HR.
Mechanical displacement of blood into pulmonary
vascular bed, which was under increased intrathoracic
pressure BP decreases
Phase IV – Recovery phase
Accumulated venous return reaches left ventricle and
increased stroke volume is pumped into constricted
systemic vascular bed causing overshoot of BP.
Overshoot detected by carotid sinuses resulting in
excitatory effect on vagus nerve leading to reflex
bradycardia.
Measure of the change of heart rate that takes place
during a brief period of forced expiration against a closed
glottis
Ratio of longest R-R interval during phase IV (within 20
beats of ending maneuver) to the shortest R-R interval
during phase II
Valsalva ratio=Longest RR
 Shortest RR
Valsalva ratio of < 1.2 is abnormal.
BP response ton standing
BP is measured when the patient is lying down and 2
minutes after the patient stands
Systolic BP fall of ≥ 20 mm Hg or diastolic BP fall of ≥ 10
mm Hg is abnormal .
Orthostatic hypotension
Orthostatic hypotension is defined as a fall in BP of 30
mm Hg systolic or 10 mm Hg diastolic BP in response
to a postural change from supine to standing.
Symptoms include weakness, faintness, dizziness,
visual impairment
Orthostatic hypotension is due to damage to the
efferent sympathetic vasomotor fibres.
BP response to isometric exercise
The patient squeezes a handgrip dynamometer to establish
his or her maximum. The patient then maintains the grip at
30% maximum for 5 minutes. BP is measured in the
contralateral arm.
A diastolic BP rise of < 16 mm Hg is abnormal.
The cold pressor test
evaluates efferent sympathetic function.
It is carried out by placing the hand in a basin filled
with 50% ice and 50% water for approximately 1 min.
 The normal average response is an increment of 20
mmHg in systolic blood pressure. The blood pressure
increase is blunted in patients with autonomic failure.
Thermoregulatory sweat testing (TST)
To evaluate the integrity of central and peripheral
sympathetic sudomotor pathways from the CNS to the
cutaneous sweat glands
The temperature is adjusted to 45–50 °C with a relative
humidity of 35–40%.
Sweat produces a change in local pH resulting in the
indicator dye changing color marking the location of
sweat production (sweat has a pH of 4.5–5.5 at low
sweat rates of 15– 100nL/gland per hour)
digital photographs are taken and a sweat density map
is generated on standard anatomical drawings
 Data are expressed as TST% which is the area of
anhydrosis/ total body area X 100
Gastrointestinal autonomic neuropathy
Esophageal dysmotility
 GERD common, dysphagia is uncommon
Gastroparesis
Enteropathy
 Nocturnal watery painless diarrhea
Constipation
Fecal incontinence
Gall bladder atony and enlargement
Clinical presentation
Classic “bloating, early satiety and postprandial fullness”

Clinical evaluation
History of drugs (opiods and TCA) and eating disorders
Metabolic evaluation – electrolytes, thyroid, addisons
Endoscopy, barium radiography,USG, MRI
Gastric emptying scintigraphy (low fat eggwhite meal –
0, 1, 2, 4 hrs imaging; retention of >10% at 4 hours, and
>70% at 2 hours defines delayed gastric emptying)
Genitourinary autonomic neuropathy
Neurogenic bladder
 Decreasedbladder sensation, hesitancy, later incomplete
evacuation and frequent UTI
Erectile dysfunction
 Neuropathy, vascular disease
Thank you