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Correspondence |
Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India, E-mail: aagarwal{at}sgpgi.ac.in
To the Editor:
Percutaneous transhepatic biliary drainage (PTBD) is one of the non-surgical modalities for treatment of obstructive jaundice.1 Dilatation of the biliary tracts is extremely painful and may be repeated a number of times over a few days.2 PTBD is generally performed under local anesthesia with sedation or general anesthesia. Epidural analgesia has been proposed as a method of choice for PTBD.2 We report the case of a 71-yr-old male, hypertensive patient, with a history of coronary artery disease and chest pain for the last 15 to 16 yr; progressive, painless jaundice for the last 45 days; and myocardial infarction during endoscopic retrograde cholangio pancreaticography 15 days earlier. In view of the progressive jaundice, urgent decompression of the biliary tract by PTBD was planned.
The patient’s chief complaints were pruritus, decreased appetite and mild fever for the last 45 days. The patient was taking sorbitrate 5 mg qid, atenolol 50 mg, and aspirin 100 mg die. His cardiac specific troponin T levels were 1.28 ng·mL–1 confirming recent myocardial infarction. Total serum bilirubin was 38.2 mg %, the direct component being 16.0 mg %, alanine aminotransferase was 108 U·L–1, aspartate aminotransferase was 98 U·L–1 and the alkaline phosphatase was 143 U·L–1. The coagulation parameters, platelet count and electrocardiography (ECG) were within normal limits. Chest x-ray revealed cardiomegaly. Concentric left ventricular hypertrophy with diastolic dysfunction was observed by echocardiography. Contrast enhanced computer tomography was suggestive of cholangiocarcinoma.
We placed an epidural catheter in the thoracic 5–6 inter vertebral space. Thereafter 6.0 mL ± 4.0 mL (0.1% bupivacaine along with 5 µg·mL–1 fentanyl) were administered via the catheter. Sensory block extended from dermatomes T2–T10. Aspirin was continued for the prevention of ischemic complications associated with unstable angina.3 Monitoring consisted of heart rate, invasive blood pressure, ECG and SpO2. During PTBD (completed in two sessions) and thereafter, the patient was without any pain or hemodynamic instability.
Thoracic epidural analgesia (TEA) in patients with coronary artery disease reduces myocardial oxygen consumption by decreasing heart rate, cardiac output and systemic vascular resistance without jeopardizing coronary perfusion pressure by blocking thoracic 1–5 sympathetic fibres. TEA favourably alters the oxygen supply/demand ratio within ischemic myocardial area.4 TEA is also effective in controlling pain in angina pectoris patients resistant to conventional medical therapy, including nitroglycerin infusion.5
We feel that TEA is a useful analgesic modality in these patients.
References
1 Baijal SS, Dhiman RK, Gupta S, et al. Percutaneous transhepatic biliary drainage in the management of obstructive jaundice. Trop Gastroenterol 1997; 18: 167–71.[Medline]
2 Barth KH. Percutaneous biliary drainage for high obstruction. Radiol Clin North Am 1990; 28: 1223–35.[Medline]
3 Samama CM, Bastien O, Forestier F, et al. Antiplatelet agents in the perioperative period: expert recommendations of the French Society of Anesthesiology and Intensive Care (SFAR) 2001 - Summary Statement. Can J Anesth 2002; 49(Suppl.): S26–35.
4 Blomberg S, Emanuelsson H, Ricksten SE. Thoracic epidural anesthesia and central hemodynamics in patients with unstable angina pectoris. Anesth Analg 1989; 69: 558–62.
5 Blomberg S, Curelaru I, Emanuelsson H, Herlitz J, Ponten J, Ricksten SE. Thoracic epidural anesthesia in patients with unstable angina pectoris. Eur Heart J 1989; 10: 437–44.
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