Dysautonomiaperioperative Implications
REVIEW ARTICLE David S. Warner, M.D., Editor Dysautonomia Perioperative Implications Hossam I. Mustafa, M.D., M.S.C.I.,* Joshua P. Fessel, M.D., Ph.D.,† John Barwise, M.D.,‡ John R. Shannon, M.D.,§ Satish R. Raj, M.D., M.S.C.I.,ʈ Andre´ Diedrich, M.D., Ph.D.,# Italo Biaggioni, M.D.,** David Robertson, M.D.†† This article has been selected for the ANESTHESIOLOGY CME Program. Learning objectives and disclosure and ordering information can be found in the CME section at the front of this issue. ABSTRACT physiologic and pharmacologic stimuli. Orthostatic hypo- tension is often the finding most commonly noted by physi- Severe autonomic failure occurs in approximately 1 in 1,000 cians, but a myriad of additional and less understood find- people. Such patients are remarkable for the striking and ings also occur. These findings include supine hypertension, sometimes paradoxic responses they manifest to a variety of altered drug sensitivity, hyperresponsiveness of blood pres- sure to hypo/hyperventilation, sleep apnea, and other neuro- * Research Fellow, Autonomic Dysfunction Center, Division of Clin- logic disturbances. ical Pharmacology, Departments of Medicine and Pharmacology, Au- In this article the authors will review the clinical patho- tonomic Rare Disease Clinical Research Consortium, Vanderbilt Uni- physiology that underlies autonomic failure, with a particu- versity Medical Center, Nashville, Tennessee. † Assistant Professor, Autonomic Dysfunction Center, Divisions of Pulmonary and Critical lar emphasis on those aspects most relevant to the care of Care Medicine, Departments of Medicine and Pharmacology, Auto- such patients in the perioperative setting. Strategies used by nomic Rare Disease Clinical Research Consortium, Vanderbilt Univer- clinicians in diagnosis and treatment of these patients, and sity Medical Center.
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