ANS

1. Clinical tests for evaluation of autonomic nervous system (June 2008). [Pg 295-Miller 7th Ed] 2. A 50 year old male and known diabetic is scheduled for upper abdominal surgery. How will you evaluate the ANS? (Dec 2009). 3. How is autonomic neuropathy evaluated preoperatively? What is its significance in anaesthesia? (June 2012). 4. What is significance of autonomic neuropathy in diabetes mellitus? How can it be assessed? (Dec 2012)

Evaluation of ANS
A] PARASYMPATHETIC a)HR RESPONSE TO VALSALVA MANOEVURE-Valsalva maneuver is a forced expiration against a closed glottis, while maintaining a pressure of 40 mm Hg for 15 sec.The Valsalva ratio is ratio of longest R-R interval which appears shortly after release to shortest R-R interval which occurs during maneuver is measured. Normal ratio is more than 1.21. b) HR RESPONSE TO STANDING-HR is measured as patient moves from resting supine to standing position. A normal tachycardia response is maximal around 15th beat after rising and relative bradycardia follows which is most marked 30th beat after standing. The 30:15 beat ratios is the ratio of the longest RR interval around 30th beat to shortest RR interval around 15th beat and it is normally more than 1.04. c)HR RESPONSE TO DEEP BREATHING (respiratory sinus arrhythmia)-when the patient takes 6 deep breaths in 1 min.The maximum and minimum HR during each cycle are measured and mean of the differences(max HR-min HR) during successive breathing cycles are observed. The normal mean difference is more than 15 beats/min.

B] SYMPATHETIC a)BP response to standing-after the patient moves from resting supine to standing position and standing systolic BP(SBP) is subtracted from supine SBP.The normal difference is more than 10mmHg. b) BP response to sustained hand grip:-the patient maintains hand grip of 30% of maximum strength for up to 5 min.The BP measured every minute and initial diastolic BP (DBP) is subtracted from DBP just before the release. The normal difference is more than 16mmHg. SIGNIFICANCE OF AUTONOMIC NEUROPATHY TO ANAESTHESIOLOGISTS 1. Increased risk of hemodynamic instability like bradycardia, hypotension, and cardiac arrest during induction and intraoperative hemodynamic disturbances. 2. Increased requirement of vasopressors. 3. MI may not be detected until profound hypotension or cardiac arrest has occurred. 4. Decreased GI motility-increased risk of regurgitation and aspiration. 5. Compensatory mechanisms to blood loss may not manifest. 6. Hypoglycemia may go unnoticed.